Potential complications:
gestational diabetes
(GDM) affects
approximately 7% of all pregnant women. The fetuses of mothers
with
hyperglycemia
are at greater risk for intrauterine death or
neonatal mortality, therefore women with GDM must be monitored
closely. GDM is associated with fetal macrosomia as well as
neonatal hypoglycemia, hypocalcemia, polycythemia and
hyperbilirubinemia.
Monitoring and treatment during pregnancy: The following
guidelines should be considered when managing inmates with GDM:
- Close surveillance of the mother and fetus must be maintained
throughout the pregnancy. Self monitoring of blood glucose
should be done on a frequent (daily) basis. Monitoring of
urinary glucose is not adequate.
- Screening for hypertension should include measurement of blood
pressure and urine protein.
- Clinical estimation of fetal size and asymmetric growth by
serial ultrasounds, especially early in the third trimester, may
identify large infants that would benefit from maternal insulin
therapy.
- All inmates with GDM should receive dietary counseling and the
provision of adequate calories and nutrients during pregnancy.
- Insulin therapy should be considered if dietary management
does not keep the fasting whole blood glucose <= 95 mg/dL or the
fasting plasma glucose
<= 105 mg/dL, or the two hour postprandial
whole blood glucose <= 120 mg/dL or the two hour postprandial
plasma glucose <= 130 mg/dL.
- Oral hypoglycemic agents should only be considered in lieu of
insulin on a case by case basis after careful consultation with
an obstetrician since their efficacy and safety are currently
being investigated.
- Breast feeding should be encouraged in women with gestational
diabetes mellitus.
Postpartum monitoring: Women with GDM are at an increased risk
for developing diabetes later in life and should be educated on
the importance of maintaining normal body weight, good nutrition,
and physical activity. If glucose levels are normal postpartum,
a screening FBG should be obtained every three years in
asymptomatic inmates. Inmates should be taught to recognize
symptoms of hyperglycemia so that they readily seek medical
attention with the onset of diabetes. Inmates with IFG or IGT
should be screened for diabetes with a FBG annually and counseled
regarding diet and a plan for aerobic exercise or increased
physical activity.
[Top]
7. MEDICAL MANAGEMENT OF DIABETIC COMPLICATIONS
Hypertension: Patients with diabetes and hypertension should
have their blood pressure lowered to targeted levels since
serious microvascular and macrovascular diabetic complications
are strongly linked to hypertension. The optimal goal of
treatment for non-pregnant diabetics > 18 years of age is a blood
pressure < 130/80 mmHg. ACE inhibitor drug therapy is indicated
for hypertensive diabetic inmates with underlying nephropathy and
should also be considered for diabetic inmates, with or without
hypertension, who have other cardiovascular risk factors.
Combination drug therapy is often required to adequately control
blood pressure in diabetic patients.
Aspirin therapy:
Aspirin therapy is an effective intervention
for preventing serious cardiovascular events such as myocardial
infarctions and stroke. Enteric-coated aspirin in dosages of 75-
325 mg/day should be considered a standard part of treatment for
most patients with diabetes, since diabetes itself is a coronary
heart disease risk equivalent. Aspirin is indicated for the
following inmates unless medically contraindicated:
- All inmates with diabetes and evidence of atherosclerosis
(e.g., coronary artery disease, peripheral vascular disease)
- As primary prevention strategy for inmates
>=
40 years of age
with one or more cardiovascular risk factors (n.b., do not
routinely use aspirin in inmates < 21 years of age due to the
increased risk of Reye's syndrome)
Dyslipidemia: Type 1 and type 2 diabetes are considered coronary
heart disease (CHD) risk equivalents due to the strong
association of diabetes and serious cardiovascular disease. Type
2 diabetes is associated with other CHD risk factors such as
elevated LDL cholesterol, low HDL cholesterol, and elevated
triglycerides. Lipid disorders should be aggressively managed in
diabetic patients to reduce the risk of serious cardiovascular
events. The therapeutic LDL goal for diabetic patients is < 100
mg/dL. Monitoring and treatment strategies for lipid disorders
should be pursued in accordance with established guidelines from
the National Cholesterol Education Program.
Diabetic nephropathy: Microalbuminuria (30 to 300 mg/24 hour) is
the earliest stage of kidney disease associated with diabetes;
often progressing to clinical albuminuria (greater than 300 mg/24
hours) with a subsequent decline in renal function over a period
of years. Hypertension usually develops during the onset of
microalbuminuria and if left untreated can hasten the progression
of renal disease. Prevention and treatment recommendations for
diabetic nephropathy include the following:
- Maximize glycemic control which will delay the onset of
microalbuminuria
- Screen for microalbuminuria
- Treat inmates with or without hypertension with
microalbuminuria with ACE inhibitors (unless medically
contraindicated);
monitor for hyperkalemia
- Lower blood pressure to < 130/80, using multi-drug therapy if
necessary
- Restrict protein intake with the onset of nephropathy
- Avoid metformin in persons with a creatinine above 1.5 due to
the risk of acidosis
- Measure creatinine clearance once renal disease is suspected
(Consultation with a physician experienced in the care of
diabetic renal disease should be considered when the GFR has
fallen to < 70 ml/minute or when the serum creatinine is > 2.0
mg/dL.)
Diabetic retinopathy: Patients with type 1 diabetes do not
usually have vision-threatening retinopathy in the first five
years of their disease. Over the next 20 years, however, nearly
all type 1 diabetics develop some retinopathy. A significant
percentage of patients with type 2 diabetes have retinopathy at
the time of diagnosis and many will develop some degree of
retinopathy over subsequent years. Retinopathy progresses in a
predictable manner, advancing from mild background abnormalities
to pre-proliferative retinopathy to proliferative retinopathy.
Vision loss occurs through the loss of central vision by macular
edema or capillary non-perfusion or by proliferative retinopathy
that can lead to retinal detachment and irreversible vision loss.
The proliferative vessels may also bleed, leading to pre-retinal
or vitreous hemorrhage. Prevention and treatment recommendations
for diabetic retinopathy include the following:
- Maximize glycemic control, since this reduces the risk of
progression to clinically significant retinopathy
- Maximize blood pressure control
- Screen diabetic patients for retinopathy since proliferative
retinopathy and macular edema may occur in completely
asymptomatic patients
- Monitor pregnant patients with diabetes closely, since
pregnancy may aggravate retinopathy
- Continue aspirin therapy (NOTE: it neither prevents
retinopathy nor increases the risk of retinal hemorrhage)
- Refer for laser photocoagulation surgery when indicated (NOTE:
photocoagulation reduces the risk of further visual loss in
patients with retinopathy, but does not ordinarily reverse
established visual loss).
Diabetic neuropathy: Peripheral diabetic neuropathy may result
in pain, loss of sensation and muscle weakness. Autonomic
neuropathy may involve the gastrointestinal, cardiovascular, and
genitourinary systems resulting in related symptoms and
complications. Neuropathy is treated by maximizing glycemic
control and addressing related symptoms.
Foot ulcers and amputations are a specific complication of
diabetes that are frequently related to neuropathy. The risk of
amputation is related to the following risk conditions:
peripheral neuropathy with a loss of sensation, evidence of
increased pressure (erythema, hemorrhage under a callus),
peripheral vascular disease (absent distal pulses), severe nail
disease, and a history of foot ulcers.
Screening for diabetic neuropathy should include monofilament
testing as outlined in Appendix 5,
The Carville Diabetic Foot
Screen that should be documented on Appendix 6, Progress Note:
Diabetic Foot Examination.
Footwear recommendations for inmates with diabetes should
consider the following:
- The current version of the BOP standard issue work shoe
addresses most concerns of diabetic and non-diabetic inmates.
- The institution is required to provide an inmate with a proper
fitting work shoe. Tennis shoes and other recreational footwear
are solely the responsibility of the inmate.
- Although in rare cases a tennis shoe may be the most
Appropriate choice for a diabetic inmate, inmates with severe
neuropathy are best served with protective footwear such as a
steel-toe work shoe or boot, which minimizes the chance that
incidental foot trauma will result in a diabetic ulcer. Extra
wide, extra deep toe boxes will minimize the risk of irritation
to feet with deformities and/or impaired sensation.
- Medically-ordered footwear should be considered in certain
circumstances, including the following:
- Symptomatic foot deformities such as large bunions,
- pronounced hammertoes, and similar conditions where regular-
issue shoes of the appropriate size and width are causing
significant skin irritation or ulceration.
- Inmates with Risk Category 2 or 3 as determined by the
Carville Foot Screen. These are inmates with loss of
protective sensation and a deformity (bunion, hammertoe,
etc.) with or without a history of a plantar ulcer, plus any
evidence of skin redness, swelling, increased skin
temperature to touch, cracking, or maceration.
- Significant vascular disease is suggested by claudication,
absent dorsalis pedis or tibialis posterior pulses or other
studies.
Dental care: The primary concern for diabetic inmates requiring
dental treatment is the avoidance of metabolic imbalances during
treatment interventions.
Inmates with uncontrolled hyperglycemia of unknown cause should
be screened carefully for an occult dental infection,
particularly following dental procedures.
Medical decompensation (hospitalization criteria): The decision
to admit inmates to an inpatient hospital unit should be made on
a case by case basis, but the following indications generally
warrant hospitalization for outpatients with diabetes:
- Diabetic ketoacidosis that is characterized by a plasma
glucose > 300 mg/dL with an arterial pH < 7.30, an increased
anion gap, and serum bicarbonate level < 15 mEq/L, along with
moderate ketones in the urine or blood. Low sodium, elevated
potassium, and elevated BUN may also occur. Total body
intracellular potassium may be significantly depleted regardless
of serum potassium levels.
- Hyperglycemic hyperosmolar state that is characterized by an
elevated serum osmolality (> 320 mOsm/kg) usually with severe
hyperglycemia (plasma glucose > 600 mg/dL) associated with an
altered mental status that may progress to coma.
- Hypoglycemia that is severe with a blood glucose < 50 mg/dL
and an altered mental status that does not readily improve with
treatment or is associated with neurologic deficits. (Note:
hypoglycemia caused by sulfonylureas can be prolonged or
recurrent due to the drugs' long duration of action. Symptomatic
hypoglycemia which cannot be managed with frequent feedings over
a 24 hour period should be treated in a hospital setting.)
- Uncontrolled hyperglycemia diagnosed during pregnancy.
- Moderate to severe hyperglycemia that is unresponsive to
standard therapies or associated with an acute illness
- Severe complications of diabetes that warrant inpatient
evaluation and treatment
[Top]
8. PERIODIC EVALUATIONS
Overview: Diabetes management requires not only dedicated
clinicians, but also the expertise of other treatment
professionals, that may include pharmacists, nurses, optometrists
or ophthalmologists, dieticians, physical therapists, and
recreation specialists. Inmate treatment plans should be
individualized, include measurable goals, and emphasize self-
management. Regularly scheduled evaluations help maximize
glycemic control, reduce diabetic complications and enhance
educational efforts. A one page summary of recommended periodic
evaluations is attached in Appendix 7, Recommendations for
Diabetic Chronic Care Clinic Monitoring.
The frequency of chronic care clinics for diabetic inmates should
be individualized, depending on the degree of glycemic control,
the complexity of the medication regimen, the frequency of
changes to the treatment regimen, the presence of complications
of diabetes and co-morbid conditions, and the inmate's
understanding of his or her disease and self motivation. Inmates
with uncomplicated diabetes controlled by diet and exercise alone
can be monitored predominantly by midlevel providers. Inmates
with chronically poorly controlled diabetes or other serious
complications such as heart or kidney disease should be monitored
closely by a physician along with the patient's midlevel
provider(s). Weekly or monthly clinician evaluations may be
necessary for brittle diabetics.
Inmates with IFG or IGT should be monitored for the development
of diabetes with periodic measurements of FBGs. One-third of
these patients will be diagnosed with diabetes within five years.
Medical history: The periodic patient interview should target
the following concerns:
- The results of glucose monitoring and review of medication
and/or insulin compliance
- Frequency, causes, and severity of any hypoglycemic symptoms
experienced since last visit
- Changes in treatment regimen or lifestyle changes made by the
inmate between clinic visits (attempt to assess the inmate's
participation in exercise, diet, and smoking cessation programs)
- Evaluation for symptoms of concurrent illnesses such as
untreated infections (e.g., tinea pedis, tinea cruris, ear
infections, and urinary tract infections)
- Screening for symptoms that suggest evolving complications,
such as paresthesias, weakness, angina, visual disturbances, skin
infections, foot problems
Physical examination: The periodic examination should target the
following (a more comprehensive physical should be conducted
annually and whenever clinically necessary):
- Vital signs and weight
- Foot exam (inspection, palpation of pulses, and an annual
sensory exam, preferably using a LEAP filament)
- Focused exam on organ systems targeted by positive responses
to interim history or presence of diabetic complications
Glucose monitoring:
- Fasting or random glucose (fingerstick or by venipuncture)
should be assessed frequently during clinician, nursing, and
pharmacist evaluations of inmates with diabetes with notation as
to the number of hours the sample is obtained postprandially.
(If recent laboratory data are not available, at a minimum, a
random fingerstick glucose should be measured as an indication of
the degree of glucose control.)
- Inmates initiating insulin therapy or making a major change in
their insulin program may need to be seen by a health care
provider as frequently as daily until glucose control is
achieved, the risk of hypoglycemia is low, and the inmate is
competent and comfortable implementing the treatment plan.
- Inmates beginning treatment by diet or oral glucose-lowering
agents may need to be seen as often as weekly until reasonable
glucose control is achieved and the inmate is competent to
conduct the treatment program.
- The frequency of health care provider monitoring of blood
glucose values should be determined on a case by case basis while
considering the following factors that affect glycemic control:
- Whether or not the inmate is self-monitoring
- Variations and degree of glycemic control as documented by
A1C levels
- Treatment with insulin versus oral agents
- Frequency of symptoms of hypoglycemia
- Frequency of prior adjustments in therapy
- Inmate motivation for self-care and the presence of
limitations such as language barriers and mental illness
- Presence of diabetic complications (e.g. diabetics with
retinopathy should be more closely monitored to protect them
from wide fluctuations in blood glucose, which is thought to
accelerate proliferative retinopathy)
- A FBG should be obtained prior to routine quarterly chronic
care evaluations.
- Periodic measurement of A1C levels is essential to assess
glucose control and compliance with therapy. Quarterly
measurements are recommended if treatment changes are made or
glucose goals are not met; otherwise, measurements two times per
year are ordinarily adequate. NOTE: A1C measurements should be
obtained just prior to a scheduled appointment to review glycemic
control. Medication adjustments should never be made based on
A1C levels which were obtained more than 30 days prior to the
appointment.
- Urine glucose monitoring has limited value, and should only be
considered as an alternative assessment of glucose control if
inmates are unable or unwilling to perform blood glucose testing.
Monitoring for diabetic complications: Inmates should receive
the following evaluations to screen for diabetic complications:
- Annual serum electrolytes and creatinine to assess renal
function
- An annual screening test for microalbuminuria for inmates with
type 1 diabetes for more than 5 years and for all inmates with
type 2 diabetes (unless proteinuria has already developed)
- An annual fasting lipid profile to screen for
hypercholesterolemia
- An annual comprehensive dilated eye and visual examination by
an ophthalmologist or optometrist for all type 1 diabetics who
have had the disease for five or more years, and for all inmates
with type 2 diabetes (Any diabetic inmates with visual symptoms
or other serious ophthalmologic problems should also have annual
eye examinations. Diabetics screened by an optometrist should be
referred to an ophthalmologist if ocular complications of
diabetes or other serious problems are identified.)
- An annual foot examination to identify risk factors for
amputation and to assess sensory loss through monofilament
testing
Inmate education: All inmates with diabetes should receive
education from a health care provider at the time of diagnosis
and periodically during health care provider evaluations and
treatments. Inmates should be counseled on the symptoms of
hyperglycemia and hypoglycemia, the natural history of diabetes
complications, the importance of glycemic control, the benefits
of healthy dietary selections and regular exercise, the
importance of modifying heart disease risk factors, and
medication benefits and side effects. Inmates with poor glycemic
control require more intensive personal or group educational
efforts. Educational materials are attached in Appendix 2, The
Food Guide Pyramid (A Guide to Daily Food Choices), Appendix 8,
Keys to Diabetes Control, and Appendix 9, Inmate Fact Sheet
(Diabetes).
Documentation: Periodic clinician evaluations should be
documented in the inmate's medical record. The chronic care flow
sheet for diabetes (BP-S670.060) is recommended for inmates who
will be monitored for more than one year.
[Top]
9. HEALTH CARE PROVIDER RESOURCES AND SELF ASSESSMENT
Provider resources for managing diabetes are listed in Appendix
10, Resources (Diabetes), and Appendix 11, Provider Self Assessment,
(Management of Diabetes) [see Part 3].
From the Federal Bureau of Prisons
September 2002
http://www.bop.gov/news/PDFs/diabetes.pdf
(PDF file)
