..

SD17049ISBN 978-616-7323-32-9

..

ISBN 978-616-7323-32-9

10,000

www.diabassocthai.org

www.thaiendoccrine.org

11000 www.dms.moph.go.th

- www.nhso.go.th

E-mail : smprt2005@yahoo.com

..

(Chronic Care Model) / / (Disease Management)

( )

..

..

( )

..

( )

.. ..

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

. .

.

..

..

..

..

(Strength of Recommendation)

++ (cost effective)

+

+/-

-

- -

(Quality of Evidence)

1 1.1 (systematic review) -

(randomized-controlled clinical trial) 1.2 - 1 (well-

designed randomized-controlled clinical trial) 2

2.1 (non-randomizedcontrolled clinical trial)

2.2 (well-designed non-randomizedcontrolled clinical trial)

..

2.3 (cohort) (case control analytic studies) /

2.4 (multiple time series) .. 2480 3

3.1 (descriptive studies) 3.2 (fair-designed controlled clinical trial)

4 4.1 (con-

sensus) 4.2

2 (anecdotal report)

..

.

.

.

.

..

. (eGFR)

.

.

.

.

.

. diabetic ketoacidosis

.

1 ..

1 (screening test) (high risk screening strategy)

1 2 2

2

1. (prevalence cross-sectional study) (prevalent case) (screening) 3

3 , (body mass index, BMI) (risk score)

Risk score = (3 x ) + (5 x BMI) + (50 x )

(BMI, body mass index) ./.2

0 () 1 () score 240 ( ) (risk score) (sensitivity) 96.8 (specificity) 24 positive predictive value negative predictivevalue 17.8 97.8

2. (cohort incidence study)

2 ..

(incident case) (prevalent case) incident diabetes prevalent diabetes (lifestyle intervention lifestyle modification) 30 6 (incident diabetes) 40-604-6

( 1, ++) 7

1. 2 8

Diabetes risk score

34 39 40 44 45 49 50

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

90 . 80 . 90 . , 80 .

( )

0012

02

035

02

02

04

3 ..

cohort study8 1 (risk score) ( 12 ) ( ++)

0-17 2

2. 2

12

2

3-5

6-8

8

5

5-10

11-20

20

1/20

1/12

1/7

1/3-1/4

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

- - - - 1-3 -

- - - - 1

4 ..

2 (prevalent case screening) (incident case screening)

1. (). 4 .. 2551-2552. : / ; 2553.

2. . : , (.) 2550. 2550, 1-16

3. Keesukphan P, Chanprasertyothin S, Ongphiphadhanakul B, Puavilai G. Thedevelopment and validation of a diabetes risk score for high-risk Thai adults, J MedAssoc Thai 2007; 90: 149-54.

4. Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, et al. Effects of diet and exercisein preventing NIDDM in people with impaired glucose tolerance: the DaQing IGT andDiabetes Study. Diabetes Care 1997; 20: 537-44.

5. Tumilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, llanne-Parikka P,et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjectswith impaired glucose tolerance. N Engl J Med 2002; 344: 1343-50.

6. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al.Reduction in the incidence of type 2 with lifestyle intervention or metformin. N EnglJ Med 2002; 346: 393-403.

7. Li G, Zhang P, Wang J, Gregg EW, Yang W, Gong Q, et al. The long-term effect oflifestyle interventions to prevent diabetes in China Da Qing Diabetes PreventionStudy: a 20-year follow-up study. Lancet 2008; 371: 1783-9.

8. Aekplakorn W, Cheepudomwit S, Bunnag P, et al. A risk score for predicting incidentdiabetes in the Thai population. Diabetes Care 2006; 29: 1872-7.

5 ..

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 (ketonuria) (ketoacidosis) - (C-peptide) / Anti-GAD, ICA, IA-2

2 95 30 2 acanthosis nigricans, polycystic ovarian syndrome

( 1)

6 ..

1. : , , . Diabetes Mellitus. 1. : 2548; 1-19.1.

2. American Diabetes Association. Diagnosis and classification of diabetes mellitus.Diabetes Care 2011; 34 (Suppl 1): S62-S69.

7 ..

2

( 1)

( ) 1-5

( 2, ++)1. 35 2. (BMI > 25 ./.2 / )

3. 4. 5.

4 6. impaired glucose tolerance (IGT) impaired

fasting glucose (IFG)7. (cardiovascular disease) 7

(waist circumference) 90

80

1. 2 10 2. 3.

8 ..

4.

1. ()

Fasting plasma glucose 1

1. 35 2. * 3. 4. ( > 250 ./. /

(< 35 ./.)5. 4 6. IGT IFG7. (cardiovascular disease)* BMI > 25 ./.2 / 90 . 80 .

fasting capillaryblood glucose

fasting plasma glucose

fasting plasma glucose

> 126 ./.

fasting plasma glucose100-125 ./.

fasting plasma glucose< 100 ./.

Impaired fasting glucose

1. 2. fasting plasma

glucose

fasting capillaryblood glucose > 100 ./.

9 ..

(fastingplasma glucose, FPG) 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 ./.4 3 ( 2, ++)

1.

200 ./.

2. 8 (FPG) > 126 ./.

3. (75 g Oral Glucose Tolerance Test, OGTT) FPG 126 ./. ( 2) 2 > 200 ./.

HbA1c standardization quality control HbA1c

10 ..

1

1.

(FPG)FPG < 100 ./. = FPG 100 125 ./. = Impaired fasting glucose (IFG)FPG > 126 ./. =

2 75 (75 g OGTT)2 h-PG < 140 ./. = 2 h-PG 140 199 ./. = Impaired glucose tolerance (IGT)2 h-PG > 200 ./. =

5,6

( 1, ++)

glucocorticoid ()

() (carotid bruit) (diabetic retinopathy) (diabeticnephropathy) (diabetic neuropathy)

1 5 FPG, HbA1c,

total cholesterol, triglyceride, HDL-cholesterol, ( LDL-cholesterol LDL-cholesterol), serum creatinine, (urinalysis) urinalysis microalbuminuria (ECG)

11 ..

1. American Diabetes Association. Diagnosis and classification of diabetes mellitus.Diabetes Care 2011; 34 (Suppl 1): S62-S69.

2. Kahn R, Alperin P, Eddy D, Borch-Johnsen K, Buse J, Feigelman J, et al. Age atinitiation and frequency of screening to detect type 2 diabetes: a cost-effectivenessanalysis. Lancet 2010; 375: 1365-74.

3. . : . , 2553; 17-46.

4. Puavilai G, Kheesukapan P, Chanprasertyotin S, et al. Random capillary plasmameasurement in the screening of diabetes mellitus in high risk subjects in Thailand.Diabetes Res Clin Pract 2001; 51: 125-31.

5. American Diabetes Association. Standards of medical care in diabetes-2011.Diabetes Care 2011; 34 (Suppl 1): S11-S61.

6. Clinical Guidelines Task Force. Global guideline for type 2 diabetes. InternationalDiabetes Federation 2005.

12 ..

13 ..

/

(lifestyle modification)

1

( ++)

7 2,3 ( ++) 5 5

1 ( ++)

(maintenance of weight loss) ( +)

( +)

14 ..

HbA1c 1-2%4 3-6

(medical nutrition therapy) 1

1.

( ++) 50-55 < 130 / ( -)

( ++) glycemic index

glycemic load ( +)

( ++)

14 1000 ( ++)

sorbitol, xylitol mannitol 5 50 . 1 . ( ++)

30-35 7 ( ++) 300 ./ ( ++) 1

( ++)

15 ..

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

( ++) ( -) 1 / 2 /

( +) 1 45 . 360 . 120 .6

( +)

( ++)

( -)

( -)

1 ( +)

( +)

( +) 10-12

( ++) ketosis ( +) ( +)

( ++)

1

16 ..

( +)

( +) 0.8 //

0.6-0.8 // ( ++) 2/3

( ++) 2000 ./ (

++) 2300 ./

( ++) 1 1160-1420 . 1 960-1420 . 1 492 . 1 2000 .7

( +)

8,9

/ ( ++)

( 2) 2 resistance 3 8-10 / 3 resistance ( ++)

17 ..

9

3

2.

150 / ( 50-70% ) 75 / 3 /2 ( ++)10

7 ( +)10

3.

(peripheralneuropathy)

ketosis ketosis

< 100 ./.

proliferative diabetic retinopathy (PDR) severe NPDR

resistance exercise

(non-weight bearing exercise)

9

( ++)

18 ..

1. Lifestyle management. In: Global guideline for type 2 diabetes. International DiabetesFederation 2005, p 22-5.

2. Diabetes prevention program research group. Reduction of the incidence of type 2diabetes with lifestyle intervention or metformin. N Engl J Med 2002: 346: 393-403.

3. Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitusby changes in lifestyle among subjects with impaired glucose tolerance. N Engl JMed 2001; 344: 1343-50.

4. American Diabetes Association. Nutrition recommendations and interventions fordiabetes 2006: a position statement of the American Diabetes Association. AnnualReview of Diabetes 2007, p 132-49.

5. . . : . , , , , . 2553, 35-55.

6. . : 21-24 2543.

7. . . 2543; 62-3.

8. Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White RD. Physicalactivity / exercise and type 2 diabetes: a consensus statement from the AmericanDiabetes Association. American Diabetes Association. Annual Review of Diabetes2007, p 167-72.

9. American Diabetes Association. Standards of medical care in diabetes-2011.Diabetes Care 2011; 34 (Suppl 1): S11-S61.

10. Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention of cardiovascular diseasesin people with diabetes mellitus: a scientific statement from the American HeartAssociation and the American Diabetes Association. Circulation 2007; 115: 114-26.

19 ..

1-4 (empowerment) 5,6

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1

(SMBG) 4

20 ..

( )

(diabetic ketoacidosis, DKA) (hyperglycemichyperosmolar non-ketotic syndrome, HHNS)

21 ..

22 ..

1. 2. 3. 4.

23 ..

5. 6.

1. Bodenheimer T, Davis C, Holman H. Helping patients adopt healthier behaviors. ClinDiabetes 2007; 25: 66-70.

2. American Diabetes Association. Standards of medical care in diabetes-2011. DiabetesCare 2011; 34 (Suppl 1): S11-S61.

3. Gary T, Genkinger J, Guallar E, Peyrot M, Brancati F. Meta-analysis of randomizededucational and behavioral interventions in type 2 diabetes. Diabetes Edu 2003; 29:488-501.

4. Steed L, Cooke D, Newman S. A systemic review of psychosocial outcomes followingeducation, self-management and psychological interventions in diabetes mellitus.Patient Educ Cons 2003; 51: 5-15.

5. International Diabetes Federation Consultative Section on Diabetes Education. TheInternational Curriculum for Diabetes Health Professional Education. InternationalDiabetes Federation 2006.

6. . , , , , . 2553.

24 ..

25 ..

3 GLP-1 analog 1 2 1-3

3 ( 1) 1. (insulin secretagogue)

(sulfonylurea) (non-sulfonylurea glinide) glucagon like polypeptide-1 (GLP-1) DPP-4 inhibitor( gliptin)

2. biguanide thiazolidinedione glitazone3. (alpha-glucosidase inhibitor)

genetic engineering

(human insulin) human insulin (insulin analog) 4 ( 10)

1. (short acting regular human insulin, RI)2. (intermediate acting insulin, NPH)3. (rapid acting insulin analog, RAA)

4. (long acting insulin analog, LAA)

26 ..

*

1.

*

HbA1c

Metformin

Sulfonylurea

Glinide

Thiazolidinedione

Alpha-glucosidaseInhibitor (-Gl)DPP-4 inhibitor

GLP-1 Analog

Insulin

/ serum creatinine 1.5 ./.

metformin 2-4 congestive heart failure

metformin thiazolidinedione ()

1-2%

1-2%

1-2%

1-1.5%

0.5-1.4%

0.5-0.8%

0.8%

1%

1.5-3.5%

27 ..

(premixed insulin) 100 RI, NPH

GLP-1 Analog GLP-1

exenatide

1,3-7

1. 2 1 4

2. 2.1 HbA1c ()2.2 ( )2.3

3.

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

4. 2 ( 1) ( 2, ++)

4.1 Repaglinide: (2, +)

28 ..

4.2 Thiazolidinedione: metformin serum creatinine > 1.5 ./. 6 ( 2, +)

4.3 Alpha-glucosidase inhibitor: sulfonylurea metformin ( 2, +) 130 ./.

4.4 DPP-4 inhibitor: sulfonylurea metformin thiazolidinedione ( 2, +)

5. 2 (combinationtherapy)3,5 2 2 / 250-350 ./. HbA1c > 9% 2 ( +) 3 3 2 ( 1) 2 3

5.1 Repaglinide: 2 3 ( +)

5.2 Thiazolidinedione: 2 ( 2, +) 3

5.3 Alpha-glucosidase inhibitor: 2 3 ( 2, +)

5.4 DDP-4 inhibitor: 2 3 ( 2, +/-) / thiazolidinedione

29 ..

2 Metformin Sulfonylurea 1. Sulfonylurea glinide 1. Metformin

2. Thiazolidinedione 2. Thiazolidinedione3. DPP-4 inhibitor 3. DPP-4 inhibitor4. Basal insulin 4. Basal insulin

: alpha glucosidase inhibitor

1. 2 ( metformin )

*

< 180 ./. HbA1c < 8%

180-250 ./.

250-350 ./.

HbA1c > 9% 2

> 300 ./.

HbA1c > 11%

> 300 ./. HbA1c > 11%

RAA = Rapid Acting Insulin AnalogRI = Regular Human InsulinNPH = Neutral Protamine Hagedorn InsulinLAA = Long Acting Insulin Analog

RI-RI-RI-NPH ---

1-3

: Glitazone Repaglinide - GI DPP-4 inhibitor

Metformin : BMI > 23 ./.2

acanthosis nigricans > 130/85 .

Elevated TG, low HDL-C

Sulfonylurea : BMI < 23 ./.2

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

LAA () NPH RI RAA

3

2 NPH (21.00-23.00 .) LAA

2 premixed insulin

premixed insulin analog

Premixed insulin Premixedinsulin analog

metformin

30 ..

6. 2 basal insulin ( 2, ++)

6.1 basal insulin ( 10) Intermediate acting insulin NPH 21.00-23.00 . Long acting insulin analog (LAA) insulin glargine insulin

detemir insulin glargine

6.2 basal insulin NPH 0.1-0.15 unit/kg/day 2-4 3-7 NPH LAA

6.3 RI basalinsulin pre-mixed insulin 1-2

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

8. 1 ( 2) 0.4-0.6 unit/kg/day NPH basal insulin RI 1/4 -

1/3 basal insulin 2 1/3 -

1/2 8.1 < 180 mg/dl 1-2

8.2 > 180 mg/dl 2-4

31 ..

1 *

*1. 1 ( > 15 ) 15

2. 5 3.

2. 1

2 RI/NPH-0-RI/NPH-0

3 4

( )

3

RAA = Rapid Acting Insulin Analog RI = Regular Human Insulin NPH = Neutral Protamine Hegadorn Insulin LAA = Long Acting Insulin Analog 0 = None

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

(LAA )

RAA RI

3 RI/NPH-0-RI - NPH

4

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

1/4 basal insulin 2 1/3

3. > 0.8 / 1 .

32 ..

1. 12. (diabetic ketoacidosis)

(hyperglycemic hyperosmolar non-ketoticsyndrome)

3. 2 2

(malnutrition)

4.

5.

1. American Diabetes Association. Standards of medical care in diabetes-2011.Diabetes Care 2011; 34 (Suppl 1): S11-S61.

2. Clinical Guidelines Task Force. Global Guideline for type 2 diabetes. InternationalDiabetes Federation 2005.

3. American College of Endocrinology / American Association of Clinical EndocrinologistsDiabetes Road Map Task Force. Road maps to achieve glycemic control in type 2diabetes mellitus. Endocr Pract 2007; 13: 261-8.

4. Ryden L, Standl E, Bartnik M, Van den Berghe G, Betteridge J, de Boer MJ, et al.Guidelines on diabetes and Cardiovascular Diseases of the European Society of Car-diology (ESC) and of the European Association for the Study of Diabetes (EASD). EurHeart J 2007; 28: 88-136.

33 ..

5. Nathan DM, Buse JB, Davidson MB, Ferranni E, Holman RR, Sherwin R, Zinman B.Management of hyperglycemia in type2 diabetes mellitus: a consensus algorithm forinitiation and adjustment of therapy. Diabetologia 2008; 51: 8-11.

6. Bhattacharyya OK, Estey EA, Cheng AYY. Update on the Canadian DiabetesAssociation 2008 clinical practice guidelines. Canadian Fam Physicians 2009; 55:39-43.

7. National Institute for Health and Clinical Excellence. NICE short clinical guideline 87.Type 2 diabetes: newer agents. London: May 2009.

34 ..

35 ..

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

SMBG1-4

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. SMBG3.1 2

SMBG / SMBG

3.2 ( 4, +/-)

36 ..

3.3 SMBG

3.4 SMBG

SMBG SMBG

1. SMBG 1-2 3

2. 3 SMBG 3 SMBG 2 . 2.00-4.00 .

3. 1 insulin pump SMBG 4-6

4. 2 SMBG 2

5. SMBG 4 4 6

6. 2 SMBG 3 / SMBG

37 ..

6

: ( 3) (finger prick device) 70%

: 10-15

25 (forearm) (thigh) (palm)

()

: 18-30

( 10-90) (photometer)

SMBG SMBG SMBG SMBG

SMBG

38 ..

1. International Diabetes Federation. Guideline: Self-monitoring of blood glucose innon-insulin treated type 2 diabetes 2009.

2. Towfigh A, Romanova M , Weinreb JE, Munjas B, et al. Self-monitoring of bloodglucose levels in patients with type 2 diabetes mellitus not taking insulin: A meta-analysis. Am J Manag Care. 2008; 14(7): 468-75.

3. Boutati EI, Raptis SA. Self-monitoring of blood glucose as part of the integral care oftype 2 diabetes. Diabetes Care 2009; 32 (Suppl2): S205-S210.

4. Diabetes UK. Care recommendations: Self monitoring of blood glucose (SMBG). Accessedon 15 September 2010 from http://www.diabetes.org.uk/About_us/Our_Views/Care_recommendations/Self-monitoring_of_blood_glucose/

5. American Diabetes Association. Standard of medical care in diabetes 2011. DiabetesCare 2011; 34 (Suppl 1): S11-S61.

6. , , . . : 1. , , . . 2548, 81-106.

39 ..

1. 2. 3. 4. 5.

1,2 1. 1,2

HbA1c < 6.5% ( 1)

2. 3 HbA 1c < 7.0%

3. 4-6

( ++)4. (

)

40 ..

1. 1-4

1-3 ( 2)

* LDL-C 70 ./.** 7,8 140 .

110 . 70 .

2 Hemoglobin A1c (% of total hemoglobin)

70-110 ./.< 140 ./.

-< 6.5%

130 ./.< 180 ./.

-7.0 - 8.0%

90 - 40 ./.> 50 ./.

< 130 .< 80 .

18.5-22.9 ./.2 < 90 . < 80 .

41 ..

/

HbA1c

1.

( 3)

HbA1c 3-6 (HbA1c )

HbA1c

42 ..

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

(/)

() HbA1c 1 (lipids profiles) 1

1,2,9-11 3

( ++) 1 microalbuminuria urine albumin/creatinine ratio

1 12

1 2 (1 45 . 120 . 360 .)

43 ..

3.

* *

**

HbA1c < 7%

proteinuria Albumin/creatinine

ratio < 30/.

retinopathy

hypertension dyslipidemia

protective sensation

peripheral pulse

HbA1c 7.0-7.9%

microabuminuria

mild NPDR

hypertension / dyslipidemia

peripheralneuropathy

peripheral pulse

serum creatinine> 2 ./. eGFR 30-59 > 7 ml/min/1.73 m2 eGFR< 30 ml/min/1.73 m2

severe NPDR PDR macular edema VA angina pectoris

CAD myocardial infarction CABG

CVA heart failure rest pain gangrene

* **

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

HbA1c > 8% hypoglycemia

3 macroproteinuria serum creatinine =

1.5 ./. eGFR 30-59 7 ml/min/1.73 m2

moderate NPDR VA

hypertension / dyslipidemia

previous amputation intermittent

claudication

44 ..

()

1. American Diabetes Association. Standards of medical care in diabetes-2011.Diabetes Care 2011; 34 (Suppl 1): S11-S61.

2. Clinical Guidelines Task Force. Global guideline for type 2 diabetes. InternationalDiabetes Federation 2005.

3. Greenfield S, Billimek J, Pellegrini F, et al. Comorbidity affects the relationshipbetween glycemic control and cardiovascular outcomes in diabetes. A cohort study.Ann Intern Med 2009; 151: 854-60.

4. Skyler JS, Bergenstal R, Bonow RO, Buse J, Deedwania P, Gale EAM, et al. Intensiveglycemic control and the prevention of cardiovascular events: Implications of theACCORD, ADVANCE, and VA Diabetes Trials: A position statement of the AmericanDiabetes Association and a scientific statement of the American College of CardiologyFoundation and the American Heart Association. Diabetes Care 2009; 32:18792.

5. Meier M, Hummel M. Cardiovascular disease and intensive glucose control in type 2diabetes mellitus: moving practice toward evidence-based strategies. Vasc HealthRisk Management 2009; 5: 85971.

6. Currie CJ, Peters JR, Tynan A, et al. Survival as a function of HbA1c in people withtype 2 diabetes: a retrospective cohort study. Lancet 2010; 375: 481-9.

7. Anderson RJ, Bahn GD, Moritz TE, et al. Blood pressure and cardiovascular diseaserisk in the Veterans Affairs Diabetes Trial (VADT). Published online before printNovember 8, 2010, doi: 10.2337/dc10-1420, Diabetes Care.

8. Cooper-DeHoff RM, Gong Y, Handberg EM, et al. Tight blood pressure control andcardiovascular outcomes among hypertensive patients with diabetes and coronaryartery disease. JAMA 2010; 304: 61-8.

45 ..

9. Mazze RS, Strock E, Simonson G, Bergenstal R. Macrovascular Diseases. In: StagedDiabetes Management: a Systemic Approach, 2nd ed. International Diabetes Center.West Sussex, England. John Wiley & Sons, Ltd 2004: 299-321.

10. . ( ). . - () , 2553.

11. Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention of cardiovascular diseasesin people with diabetes mellitus: a scientific statement from the American HeartAssociation and the American Diabetes Association. Circulation 2007; 115: 114-26.

12. .. 2552. 2552

46 ..

47 ..

1,2

1.

2.

3.

3

(Whipple triad) < 70 ./.,

< 70 ./. < 50 ./. < 70 ./. (glucose counter-regulatory system)

2 (autonomic symptom) (neuroglycopenic symptom)

1.

2. cognitive (hemiparesis) (stroke), /

1 2

48 ..

(hypoglycemia unawareness)1,3,4

4 1,2

1. Documented symptomatic hypoglycemia < 70 ./.

2. Asymptomatic hypoglycemia < 70 ./.

3. Probable symptomatic hypoglycemia

4. Relative hypoglycemia > 70 ./.

3

1,5 1. (mild hypoglycemia)

2. (moderate hypoglycemia)

3. (severe hypoglycemia) 1

49 ..

6-10 ( 4)

(insulin secretagogue) sulfonylurea glinide1,5

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

1

1.

2.

3. 4. (endogenous hepatic glucose production)

5. (insulin sensitivity)

6. /

7. 8. HbA1c /

9. 10.

50 ..

2 1 2 11

1,12

1. 15

30 11 15 3 180 . 180 . 3 1 240 . 2 1/2 1 15-20

2. () 15-20

3. 15 < 70 ./.

4. > 80 ./. 1 (snack) 15

5.

6.

( ) (complex carbohydrate)

51 ..

-

1. 1 . 2.

-

-

1. 1 . 2.

10-15 15 50%

- 50% ( 1)

1. 20 1

2. 10 . ()

3.

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

5. 50% 10-20 .

52 ..

50% 30-40 . 50% 50 .

6. 50% 50%

7. 50% 50 . 10%(10%D) 2 ./ 1 ./ ( 60 ./ 50 .) 80 ./. 120 ./. sulfonylurea 6

8. 10% (10%D) 2 ./ 1 ./ 60 ./ 50 .

9. 10%D 10. 10%D

15-30 11. 10%D

10%D ( osmotic diarrhea ) sulfonylurea octreotide 50-100 8-12 , diazoxide 100 . 8 dexamethasone 5 . 6

12. 10%D

13.

53 ..

1.

-

15 3 , 180 ., 180 ., 3 ., 1 , 1 , 1/2

15 15

< 70 ./.

> 80 ./.

< 70 ./.

:

() 0.5 . ( < 5 ) 1 . ( > 5 )

: ,, 50% 10-20. bolus heparin saline lock 5-10%

15 > 80 ./.

, ,

, , , ,, ,

, , , cognitive ,, , , , , , , ,,

( )

-

54 ..

10%D 10%D ( 10%D 5%D )

14.

15. 15-30 > 80 ./. 3 (posthypoglycemic brain edema) dexamethasone 5 . 6 /20% mannitol 300 .

< 70 ./. ( 2, +)1

sulfonylurea ( 1, ++)1

(microvascularcomplication) ( 1, ++)1

( 2, ++)1

(diabetescare team) ( 1, ++)1

1 ( 1, ++)

55 ..

1. (regimen) sulfonylurea glinide

2. 3. (self-monitoring of blood

glucose, SMBG)4. (diabetes self-management)

5.

6. 2-3 12 ( 1, +)1

( 1, ++)1 15 38./. 20 20 65 ./. 45 30 5 15-30

( 1, ++)

2 50% ( 1, ++) 50% ( 1, +)

56 ..

1. Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER, Service FJ.Evaluation and management of adult hypoglycemic disorders: an Endocrine SocietyClinical Practice Guideline. J Clin Endocrinol Metab 2009; 94: 70928.

2. American Diabetes Association Workgroup on Hypoglycemia. Defining and reportinghypoglycemia in diabetes: a report from the American Diabetes Association Workgroupon Hypoglycemia. Diabetes Care 2005; 28: 1245-9.

3. Dagogo-Jack SE, Craft S, Cryer PE. Hypoglycemia-associated autonomic failure ininsulin-dependent diabetes mellitus. Recent antecedent hypoglycemia reducesautonomic 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 inadvanced type 2 diabetes. Diabetes 2002; 51: 72433.

5. Yale JF, Begg I, Gerstein H, Houlden R, Jones H, Meheux P, Pacaud D. 2001 CanadianDiabetes Association Clinical Practice Guidelines for the prevention and managementof 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: 868870.

7. Laing SP, Swerdlow AJ, Slater SD, Botha JL, Burden AC, Waugh NR, et al. The BritishDiabetic Association Cohort Study, II: cause-specific mortality in patients withinsulin-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 ofintensive glucose lowering in type 2 diabetes. The Action to Control CardiovascularRisk 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. forthe ADVANCE Collaborative Group. Severe hypoglycemia and risks of vascular eventsand 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.

57 ..

12. Fanelli CG, Epifano L, Rambotti AM, Pampanelli S, Di Vincenzo A, Modarelli F, et al.Meticulous prevention of hypoglycemia normalizes the glycemic thresholds andmagnitude of most of neuroendocrine responses to, symptoms of, and cognitivefunction during hypoglycemia in intensively treated patients with short-term IDDM.Diabetes 1993; 42: 16839.

58 ..

59 ..

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

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

(moderate) (severe)2. Proliferative diabetic retinopathy, (PDR)

3. Diabetic macula edema

NPDR

HbA1c PDR macula edema

5,6

( 1) visual

acuity ( 2, ++) digital camera ( 4, ++)

60 ..

1 5 12 1 ( ++)

2 ( ++)

> 126 ./.

1.

1

2

5 12

No DR Mild NPDR Severe NPDR PDR Macula edema

1 6 3-6

Moderate NPDR

61 ..

HbA1c 7% ( 1, ++) HbA1c 6.5% ( ++)

130/80 1,5,6

( ++) 1,7,8

( +) severe NPDR PDR Macula edema

( ++)

( ++)

( ++)

( ++)

( ++)

( +)

3 ( ++)

62 ..

2. (Alb/Cr = albumin creatinine ratio)

12

urine protein()

microalbuminuria albumin/creatinine ratio (Alb/Cr)

dipstick specific microalbumin

Alb/Cr < 30 mg/g microalbumindipstick < 20 mg/l

Alb/Cr 30-299 mg/g microalbumindipstick > 20 mg/l

Alb/Cr > 300 mg/g microalbumindipstick > 100 mg/l

1-2 6 2 3

serum Cr > 2 mg/dL eGFR < 60 ml/min

ACEI ACEI ARB

microalbuminuria

63 ..

(diabetic nephropathy) diabetic nephropathy

8-10 ( 1) 30-299 microalbuminuria 300 macroproteinuria (overtdiabetic nephropathy)

11-12

( 2) 1 5

2 ( 2, ++)

urine protein albuminuria dipstick

macroalbuminuria macroproteinuria

dipstick urinaryalbumin creatinine ratio (Alb/Cr) Alb/Cr 30-299 ./ dipstick microalbuminuria microalbuminuria 20 ./ 1-2 6 microalbuminuria 2 3

(estimated GFR, eGFR)12 serum creatinine ( 2, ++) serum creatinine 5

11,12

1. microalbuminuria

( ++)

64 ..

130/80 ( ++)

2. microalbuminuria (incipient nephropathy)

microalbuminuria (chronic kidney disease,CKD) ( ++)

130/80 ( ++) angiotensinconverting enzyme inhibitor (ACEI) angiotensin II receptor blocker (ARB) ( ++)

0.8 ( ++)

aminoglycoside

diabetic retinopathy 3. macroalbuminuria (clinical or overt diabetic nephropathy)

130/80 ( ++)

ACEI ARB ( ++)

diabetic retinopathy

60 //1.73.2 serum creatinine 2 ./. ( ++)

4. (end stage renal disease) 30 /

( ++)

65 ..

1. Chetthakul T, Deerochanawong S, Suwanwalaikorn S, et al. Thailand DiabetesRegistry Project: Prevalence of diabetic retinopathy and associated factors in type 2diabetes mellitus. J Med Assoc Thai 2006; 89 (Suppl 1): S27-S36.

2. Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions andComplications Research Group. Retinopathy and nephropathy in patients with type 1diabetes four years after a trial of intensive therapy. N Engl J Med 2000; 342: 381-9.

3. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HAW. 10-Year Follow-up ofintensive glucose control in type 2 diabetes. N Engl J Med 2008; 359: 1577-89.

4. American Diabetes Association. Standards of medical care in diabetes-2011.Diabetes Care 2011; 34 (Suppl 1): S11-S61.

5. . ( ). . - () , 2553.

6. Holman RR, Paul SK, Bethel MA, Neil HAW, Matthews DR. Long-term follow-up aftertight control of blood pressure in type 2 diabetes. N Engl J Med 2008; 359: 1565-76.

7. Keech A, Mitchell P, Summanen P, et al. Effect of fenofibrate on the need for lasertreatment for diabetic retinopathy (FIELD study): a randomized controlled trial.Lancet 2007; 370: 1687-97.

8. 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.

9. National Kidney Foundation: K/DOQI Clinical practice guidelines for chronic kidneydisease: evaluation, classification and stratification. Am J Kidney Dis 2002; 39 (Suppl1): S1-S266

10. Eknoyan G, Hostetter T, Bakris G, et al. Proteinuria and other markers of chronickidney disease: a position statement of the National Kidney Foundation (NKF) andthe National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Am JKidney Dis 2003; 42: 617-22

11. Kramer H, Molitch M. Screening for kidney disease in adults with diabetes. DiabetesCare 2005; 28: 1813-6

12. .. 2552. 2552

66 ..

66 ..

67 ..

1,2

2 3

4 ( 1, ++)

peripheral arterial disease albuminuria microalbuminuria macroalbuminuria

(Primary prevention)

130/80 . (

2, ++) 120 .

68 ..

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-blockerACEI diabetic nephropathy ARB

ACEI ACEI ARB serumpotassium serum creatinine ( 1, ++)

ACEI ARB ARB ACEI

Beta-blocker tachyarrhythmiasCalcium-channel blocker

LDL-C4,6,7

100 ./. LDL-C

statin2,7,8 ( 1, ++) 40 statin

40 LDL-C 100-129 ./.

HDL-C triglyceride7

triglyceride 200-499 ./. non-HDL-C

2 LDL-C non-HDL-C 130 ./. (non-HDL-C HDL-C )

non-HDL-C statin fibrate niacin

69 ..

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

8,9 ( 2, ++) HbA1c 6.5% 7.0% HbA1c 7% 8%

- - - - (short life expectancy)

( 1, ++) antiplatelet antiplatelet 50

60 4,7 albuminuria

antiplatelet aspirin 60-162 ./ ( 1, ++)

(Secondary prevention)

2,8,9 2 ( 1, ++)

< 130/80 . 110 .10 70 .11

beta-blocker LDL-C 70 ./. statin ( 1, ++) HDL-C triglyceride

( 2, ++)

70 ..

antiplatelet antiplatelet aspirin 60-162 ./

aspirin antiplatelet clopidogrel

( 2, ++)

1. Gaede P, Lund-Anderseo H, parving HH, Pedersen O. Effect of a multifactorialintervention on mortality in type 2 diabetes. New Engl J Med 2008; 358: 580-91.

2. Li R, Zhang P, Barker LE, Chowdhury FM, Zhang X. Cost-effectiveness of interventionsto 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 inasymptomatic diabetic subjects: the DIAD study. Diabetes Care 2004; 27: 1954-61.

4. American Diabetes Association. Standards of medical care in diabetes-2011.Diabetes Care 2011; 34 (Suppl 1): S11-S61.

5. The ACCORD Study Group. Effects of intensive blood-pressure control in type 2diabetes mellitus. New Engl J Med 2010; 362: 1575-85.

6. .. 2551 . Thai Hypertension Society: Guidelines in the treatment of hyper-tension 2008.

7. Brunzell JD, Davidson M, Furberg CD, et al. Lipoprotein management in patients withcardiometabolic risk: Consensus conference report from the American DiabetesAssociation and the American College of Cardiology Foundation. J Am Coll Cardiol2008; 51: 1512-24.

8. Skyler JS, Bergenstal R, Bonow RO, et al. Intensive glycemic control and theprevention of cardiovascular events: Implications of the ACCORD, ADVANCE and VADiabetes Trials. A position statement of the American Diabetes Association and thescientific statement of the American College of Cardiology Foundation and the AmericanHeart Association. Circulation 2009; 119: 351-7.

9. Greenfield S, Billimek J, Pellegrini F, et al. Comorbidity affects the relationshipbetween glycemic control and cardiovascular outcomes in diabetes. A cohort study.Ann Intern Med 2009; 151: 854-60.

71 ..

10. Cooper-DeHoff RM, Gong Y, Handberg EM, et al. Tight blood pressure control andcardiovascular outcomes among hypertensive patients with diabetes and coronaryartery disease. JAMA 2010; 304: 61-8.

11. Anderson RJ, Bahn GD, Moritz TE, et al. Blood pressure and cardiovascular diseaserisk in the Veterans Affairs Diabetes Trial. Diabetes Care 2011; 34: 34-8.

72 ..

73 ..

(lower limb amputation) 1-3

2,4

( 1, ++)5

(foot examination) 1 (risk category) 6 ( 1, ++) (foot inspection) 6 ( 1, ++)

7-9 ( 1, ++)( 6)

(peripheral vascular disease) 2,4

(arterial bypass surgery) ( 4, +)

1-4,10,11

( 1) ( 1) ( 1)

74 ..

( 1) (foot deformities) ( 2) (callus) ( 2) ( 2) ( 2) ( 2) 10 ( 2) ( 2) HbA1c ( 2) ( 2) ( 2) ( 2) ( 2)

2

2

( 1)

( ++) (self foot-care)

( ++) ( 6)

75 ..

( ++)

( ++)

1.

,

6

1

-

/ ABI

> 0.9

,

1

-

/

ABI < 0.9

,

6-12

-

/ ABI < 0.9

76 ..

1 ( ++) ( ++)

( ++) 6-12 ( ++) ( ++) ( ++)

( ++) 6 ( ++) ( ++) /

( ++) /

12 ( 1, +)

( )

( ++) ( ) (

gangrene) (callus) ( ++)

(ingrown toenail) ( ) ( ++)

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

77 ..

neuropathy ( ++) ankle reflex ( ++) 128 ( ++) Semmes-Weinstein monofilament 5.07 10 ( ++) monofilament 1,13-15 ( 1) ( 7)

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

( ++) ( 8)

(neuropathic ulcer)

(ischemic ulcer) (acute ulcer) ( ++) ( 9)

() Wagner Meggitt16 ( ++) ( 9)

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

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

( ++) ( ++)

78 ..

(Wagner grade 1 < 2 . 0.5 .

< 2 .) 2,17 ( 4, ++)

1-2 18 ( 1, ++) ( 9)

18 ( 4, ++)

(local antibiotic) 18 ( 2, +/-)

2 ( ++)

( > 2 . > 0.5 .

> 2 . Wagner grade 2 ) 2,17 ( 4, ++)

(biopsy) (curettage) discharge 18 ( 1, ++)

6 osteomyelitis 18 ( 4, +)

2-4 6 osteomyelitis18 ( 1, ++)

vascular insufficiency bypass surgery ( +) debridement

( ++) contact cast (shoe modification) (custom moldedshoes) 2 ( 2, +/-)

hyperbaric oxygen, granulocyte-colony stimulatingfactor, growth factor, electrical stimulation 2 ( 2, -)

79 ..

1. Crawford F, lnkster M, Kleijnen J, Fahey T. Predicting foot ulcers in patients withdiabetes: a systematic review and meta-analysis. QJM 2007; 100: 65-86.

2. Mclntosch A, Peters JR, Young RJ, et al. Prevention and management of footproblems in type 2 diabetes: Clinical guidelines and evidence 2003. (full NICEguideline). Sheffield: University of Sheffield. www.nice.org.uk

3. Sriussadaporn S, Mekanandha P, Vannasaeng S, et al. Factors associated withdiabetic foot ulceration in Thailand: a case-control study. Diabet Med 1997; 14: 50-6.

4. American Diabetes Association. Standards of medical care in diabetes-2011.Diabetes Care 2011; 34 (Suppl 1): S11-S61.

5. Donohoe ME, Fletton JA, Hook A, et al. Improving foot care for people with diabetesmellitus-a randomized controlled trial of an integrated care approach. Diabet Med2000; 17: 581-7.

6. McCabe CJ, Stevenson RC, Dolan AM. Evaluation of a diabetic foot screening andprotection programme. Diabet Med 1998; 15: 80-4.

7. Valk GD, Kriegsman DM, Assendelft WJ. Patient education for preventing diabeticfoot ulceration. A systematic review. Endocrinol Metab Clin North Am 2002; 31:633-58.

8. Litzelman DK, Slemenda CW, Langefeld CD, et al. Reduction of lower extremityclinical abnormalities in patients with non-insulin dependent diabetes. Ann lnternMed 1993; 119: 36-41.

9. Barth R, Campbell LV, Allen S, Jupp JJ, Chisholm DJ. Intensive education improvesknowledge, compliance and foot problems in type 2 diabetes. Diabet Med 1991;8: 111-7.

10. Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM. Preventive foot care inpeople with diabetes (Technical Review). Diabetes Care 1998; 21: 2161-77.

11. Sriussadaporn S, Ploybutr S, Nitiyanant W, Vannasaeng S, Vichayanrat A. Behavior inself-care of the foot and foot ulcers in Thai non-insulin dependent diabetes mellitus.J Med Assoc Thai 1998; 81: 29-36.

12. Reiber GE, Smith DG, Wallace C, et al. Effect of therapeutic footwear on footre-ulceration in patients with diabetes. A randomized controlled trial. JAMA 2002;287: 2552-9.

80 ..

13. Rith-Najarian SJ, Stolusky T, Gohdes DM. Identifying diabetic patients at high risk forlower-extremity amputation in a primary health care setting. A prospectiveevaluation of simple screening criteria. Diabetes Care 1992; 15: 1386-9.

14. Pham H, Armstrong DG, Harvey C, Harkless LB, Giurini JM, Veves A. Screeningtechniques to identify people at high risk for diabetic foot ulceration: a prospectivemulticenter trial. Diabetes Care 2000; 23: 606-11.

15. Pacaud D, Singer D, McConnell B, Yale J-F. Assessment of screening practices forperipheral neuropathy in people with diabetes. Can J Diab Care 1999; 23: 21-5.

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

17. Klein R, Levin M, Pfeifer M Rith-Najarian SJ. Detection and treatment of footcomplications. In: Mazze RS, Strock ES, Simonson GD, Bergenstal RM, eds. StagedDiabetes Management a Systematic Approach, 2nd ed. West Sussex: John wiley &Sons; 2004; 353-65.

18. Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic footinfections. IDSA guidelines. Clinical Infectious Diseases 2004; 39: 885-910.

81 ..

1

2 10 2 3 1. 2. (BP > 130/85 .)3. acanthosis nigricans( ++) 1 1

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

OGTT

( 2) ( 5)

( 10)

82 ..

1. 2 ( 10 )

Capillary blood glucose> 110 ./.

Fasting plasma glucose> 126 ./. x 2

10 1. ( 120) 2. 2 3

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

5-10

1

OGTT

(2-hr plasmaglucose > 200

./.)

IGT(2-hr plasma

glucose 140-199 ./.)

1

: 15

1. 2.

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

1.

2.

3. Biguanide Sulfonyluea

4.

83 ..

2. 1

DKA1. 2.

4 /

3. 1-3 HbA1c 3

Random capillaryblood glucose (RCBG)

RCBG < 110 ./.

RCBG > 200 ./.

RCBG 110-199 ./.

plasma glucose < 200 ./.

Fasting plasma glucose> 126 ./. x 2

: 15

, ,

plasma glucose > 200 ./.

plasma

glucose

DKA 11

84 ..

1. 1 ( 2)

1.1 1.2

( 12 )

1.3 - (prepubertal age) = 0.7-1.0 /./- (pubertal age) = 1-1.5 /./

2 - 2 / (conventional method)

(NPH) (regular insulin, RI) (biphasic insulin analogue) 2/3 1/3

- 3-4 / (intensive method) 3 /

, 2/3 1/3

4 / basal-bolus insulin basal insulin 1-2 (bolus insulin) 30-50 basal insulin 50-70 bolus insulin

HbA1c ()

85 ..

1.4 ( 1) 50-60 25-30 15-20 70 5 2 : 1 ( ++)

1.

() ()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

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

conventional method 3 2-3 intensive method basal-bolus insulin 3-4

1.5 (diabetes education and skillsfor self-care) 7-10

- 1 -

86 ..

-

- 3-4 250 ./.

-

- - - -

1.6

(psycho-social adjustment and familysupport)

-

-

-

-

-

1.7 1

3 3-6 2 ( ++)

87 ..

2. 2 ( 1)2.1

4 2.2 biguanide

sulfonylurea 200 ./. HbA1c > 8 7.5% 1-3

2.3

2.4 (diabetes education and skills forself care) 7-10

- 2 -

-

2.5

(psycho-social adjustment and familysupport) 1

HbA1c

2

88 ..

HbA1c*(microalbuminuria)

** freeT4 TSH

3-6

1

10 1 5 1 10 5 2 1

* 2**

- 2 > 10 -

2.

0-6 100 - 180 ./.

110 - 200 ./. (HbA1c) 7.5 - 8.5%

6-12 90 - 180 ./. 100 - 180 ./. (HbA1c) < 8%

13 90 - 130 ./. 90 - 150 ./. (HbA1c) < 7.5%

3

3.

89 ..

3 6-12 1. (medical outcome)

- HbA1c- - -

HbA1c DKA 2

2. (psychosocial) - - - -

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

1. HbA1c 8.5% 1 7% 22. DKA 6 3. hypoglycemia hypoglycemia unawareness

1. American Diabetes Association. Standards of medical care in diabetes-2011.Diabetes Care 2011; 34 (Suppl 1): S11-S61.

2. International Society for Pediatric and Adolescent Diabetes. Consensus Guideline2000: ISPAD Consensus guidelines for the management of type 1 diabetes mellitus inchildren and adolescent. Medical Forum International. Zeist Netherlands 2000;11-19R.

90 ..

3. Likitmaskul S, Wekawanich J, Wongarn R, Chaichanwatanakul K, Kiattisakthavee P,Nimkarn S, et al. Intensive diabetes education program and multidisciplinary teamapproach in management of newly diagnosed type 1 diabetes mellitus: a greaterpatient benefit, experience at Siriraj Hospital. J Med Assoc Thai 2002; 85 (Suppl 2):S488-95.

4. National Collaborating Center for Womans and Childrens Health. Type 1 diabetesdiagnosis and management of type 1 diabetes in children and young people: clinicalguideline 2004. RCOG Press London.

5. Bangstad HJ, Danne T, Deeb LC, Jaroz-Chabot P, Urakami T, Hanas R. Insulintreatment in children and adolescents with diabetes. Pediatric Diabetes 2009; 10(Suppl 12): 82-99.

6. Bode BW, Davidson PC, Steed RD, Robertson DG, Skyler JS, editors. How to controland manage diabetes mellitus. Alexandria: American Diabetes Association; 2001.

7. Garg A, Barnett JP. Nutritional management of the person with diabetes. In: Porte DJr, Sherwin RS, Baron A, editors. Ellenberg & Rifkins diabetes mellitus. 6th ed. NewYork: McGraw-Hill; 2003. p.437-52

8. Likitmaskul S, Santipraphob J, Nakavachara P, Sriussadaporn P, Parkpreaw C, KolatatT and 31 members. A holistic care and self management education programe forchildren and adolescents with diabetes at Siriraj Hospital. Abstract presented inInternational Conference on Health Promotion and Quality in Health Services. 19-21November 2008, Bangkok, Thailand. p 253-55.

91 ..

(hypo-glycemia) (moderate hyperglycemia) (diabetic ketoacidosis, DKA)

(hypoglycemia)I. 1,2

(autonomic symptom) (neuroglycopenicsymptom)

II.

1 2 2 /

92 ..

1,2 11. (mild hypoglycemia)

1.1 70 ./. (

) () 20 -30

1.2 70 ./.

20-30 5-10 10-15

10

- soft drink 90 - 3-4 - 1 - 20-30

15 (1 )

- 1 (200 )- 1 - 200 - 1

30-60 80 ./.

2. (moderate hypoglycemia) < 70 ./.

10 - soft drink 90 - 3-4 - 1 - 20-30

93 ..

15 (1 )

- 1 (250 )- 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

III.

94 ..

(moderate hyperglycemia) diabetic ketoacidosis (DKA)3-5

DKA 1 250 ./. DKA (ketone)

1. 1.1

- - - 250 ./.

5-10

1.2 - /- 2-4 2 -

10-20- 4-6

180 ./. - 8

2.

2.1 - 4 - (2-4 4 )-

1

95 ..

2.2 2.2.1

DKA - /- 2-4 2 - regular insulin 0.1-0.25 unit/kg/dose 4-6

NPH regular insulin- 2-4

4-6 8- 24 24

2.2.2. DKA acetone ( 11 Diabetic ketoacidosis )

1. Silink M, et al. hypoglycemia. In: Silink M, ed. APEG Handbook on Childhood andAdolescent 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 managementof hypoglycemia in children and adolescents with diabetes: ISPAD Clinical PracticeConsensus Guideline 2009. Pediatric Diabetes 2009:10 (Suppl 12): 134-45.

3. American Diabetes Association. Standards of medical care in diabetes 2011. DiabetesCare 2011; 34 (Suppl 1): S11- S61.

4. Wolfsdort J, Craig ME, Daneman D, et al. Diabetes ketoacidosis in children andadolescents with diabetes: ISPAD Clinical Practice Consensus Guideline 2009. PediatricDiabetes 2009:10 (Suppl 12): 118-33.

5. . (Managementfor diabetic ketoacidosis). 2545: 41 (1): 115-22.

96 ..

96 ..

97 ..

2 (pre-gestational diabetes) (gestationaldiabetes)1,2 (team approach) (tight control) ( 9) (conception) 2-3 2 ( 1, ++)

2-3

HbA1c 6.5% 2

( 1)

1.

(./.) 60-95 1 < 140 2 < 120 2.00 4.00 > 60

proliferative diabetic retinopathy

98 ..

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 analog) lispro insulin, aspart insulin (regular human insulin) glargine insulin long acting insulin analog IGF-1 receptor insulin detemir

2 ( 2, ++)

99 ..

10-12 8 ( 2, ++)

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

1 180 ./. ( 2, +)

70-120 ./.

ketosis 5% 100-125 ./ 1-2 (normal saline) 1-2 /

100 ..

(caesarian section) 5% 100-125 ./ 1-2 5% 70-120 ./. (normal saline) 1-2 / 70-140 ./.

2 4-6 400

(Gestational diabetes)

(glucose intolerance) 1-14 ( 2) ( 12)

25 24-28 50 (50 g glucose challenge test) 1 140 ./. oralglucose tolerance test (OGTT) ( 2) National Diabetes Data Group (NDDG) American College of Obstetricians and Gynecologist

101 ..

pregestational diabetes

1 105 ./. 95 ./. 1 . 2 . 140 120 ./. 1-2 ( 1, ++) glibenclamide metformin metformin ( 3, +)

7.4 5 6 75 (75 g oral glucose tolerance test, OGTT) 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 NDDGand WHO criteria for detecting gestational diabetes. Diabetologia 1996; 39: 1070-3.

4. The HAPO study cooperative research group. Hyperglycemia and adverse pregnancyoutcomes. New Engl J Med 2008; 358: 1991-202.

5. Bellamy L, Casas JP, Hingoranai AB, Williams D. Type 2 diabetes mellitus aftergestational diabetes: a systemic review and meta-analysis. Lancet 2009; 373: 1273-9.

102 ..

103 ..

Wagners Chronic Care Model (CCM) WHOs Chronic Care Model1,2 3,4

( )

()

104 ..

/

/

5

(Prevalence) (Incidence) fasting plasma glucose (FPG = 70 -

< 130 ./.) HbA1c HbA1c 7% lipid profile LDL-C 100 ./. 130/80 . microalbuminuria

105 ..

microalbuminuria ACE inhibitor ARB

1 diabetic retinopathy diabetic nephropathy myocardial infarction cerebral infarction impaired fasting glucose (IFG) / /

(..)

1. King H, Gruber W, Lander T. lmplementing national diabetes programmes. Report ofa WHO Meeting. World Heath Organization. Division of Non-communicable Diseases,Geneva 1995.

2. Wagner EH. Chronic Disease Management: What will it take to improve care forchronic illness? Effective Clinical Practice 1998; 1: 2-4.http://www.improvingchroniccare.org/change/model/ components.html >>verified2/5/2007

3. U.S. Department of Health and Human Service, 2006 National Healthcare QualityReport AHRQ. Publication No 07-0013, December 2006.

4. American Diabetes Association. Standards of medical care in diabetes-2011.Diabetes Care 2011; 34 (Suppl 1): S11-S61.

5. TCEN - . 2552.

106 ..

107 ..

1-3

1. 2. 3.

() (capillary blood glucose, CBG) glucose meter point-of-care-device ( 7)

1

108 ..

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

1. CBG < 70 ./.2. hypoglycemia 3. CBG > 200 ./. 2 4. CBG > 300 ./.5. 6. 7. 8. tachycardia ( > 100 /) / orthostatic hypotension9. / 10. 180/110 .

systolic BP > 130 . / diastolic BP > 80 . 3

11.

12. 13. 14.

hyperglycemia hypoglycemia

109 ..

1.

6

6

/

:

:

5 CBG > 130 ./. 3

(medication error)

(drug interaction) -- - -/

( )

(non-compliance)

1 ()

(CBG < 130 ./.)

CBG > 130 ./.3

/

110 ..

15.

16.

3

1) (non-compliance)

2)

3)

111 ..

1. Katherine K, Max, R, Anandi L, et al. The role of community pharmacies in diabetescare: eight case studies. California Healthcare Foundation 2005. Available at: http://www.chcf.org/topics/chronicdsease/index.cfm?itemID=112672. Accessed November11, 2006

2. Stacy AM, Kim RK, Warren AN. Identifying at-risk patient through communitypharmacy-based hypertension and stroke prevention screening projects. J AM PharmAssoc 2003; 43: 50-5

3. World Health Organization. Diabetes Mellitus Available at: http://www.who.int/topics/diabetes_mellitus/en./. Accessed November 11, 2006

112 ..

114 ..

115 ..

1. 1 (type 1 diabetes, T1D)

1.1 Immune mediated1.2 Idiopathic

2 2 (type 2 diabetes, T2D)2.1 Predominant insulin resistance2.2 Predominant insulin secretory deficiency

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

3.2 Type A insulin resisitance, Leprechaunism, Lipoatrophic diabetes

3.3 Hemochromatosis

3.4 Acromegaly, Cushing syndrome,Pheochromocytoma, Hyperthyroidism

3.5 Pentamidine, Steroid,Dilantin, -interferon, Vacor

3.6 Congenital rubella, Cytomegalovirus3.7 Anti-insulin receptor

antibodies, Stiff-man syndrome3.8 Down syndrome, Turner

syndrome, Klinefelter syndrome, Prader-Willi syndrome, Friedrichs ataxia, Huntingtonschorea, Myotonic dystrophy

4 (gestational diabetes mellitus, GDM)

116 ..

117 ..

(Oral Glucose Tolerance Test)

() 1.

150 3

2.

3. 10-16 10 FPG 16

4. (fasting venous blood sample) 75 250-300 . 5 2 30

5. 6 . 1 .,

1.75 / 1 75

(gestational diabetes mellitus)

GDM oral glucose tolerance test National Diabetes Data Group(NDDG) 3 hour oral glucose tolerance test 8 100 250-300 .

118 ..

1, 2 3 2 1, 2 3 105, 190, 165 145 ./. IADPSG(International Association Diabetes Pregnancy Study Group) 75 OGTT 92, 180 153 ./. 1 2

NDDG = National Diabetes Data Group; ADA = American Diabetes Association,IADPSG = International Association of Diabetes Pregnancy Study Group

1 2 3

NDDG 100 105 190 165 145 > 2 Carpenter & Couston 100 95 180 155 140 > 2 ADA 75 95 180 155 - > 2 WHO 75 < 126 - 140 - 2 IADPSG 75 92 180 153 -

(./.) () GDM

119 ..

SMBG SMBG

1 2 SMBG SMBG1 meta-analysis stratified SMBG SMBG

1. SMBG (HbA1c)

2. SMBG (real time)

3.

4. 2 SMBG

/

HbA1c /

120 ..

( )

SMBG2

1. -

- -

2. - -

-

3. -

2 1

4. -

()- - (PaO2) PaO2 150 .

biosensor (glucose oxidase)

121 ..

GDH-PQQ = glucose dehydrogenase pyrroloquinoline quinone; GDH NAD = glucose dehydrogenase-nicotine adenine dinucleotide;GO = glucose oxidase; C = capillary; V = vein; A = artery ; N = neonate; RH = relative humidity

Surestep

Abbott Abbott Roche Roche Roche Terumo

Biosensor Biosensor Photometry Photometry Biosensor Photometry Biosensor Biosensor Biosensor

GDH-PQQ GDH-PQQ GDH-PQQ GO GO GO GO GO GDH-NAD

Whole blood Whole blood Whole blood Whole blood Whole blood Whole blood Whole blood Whole blood Whole blood

Plasma Whole blood Plasma Plasma Plasma Plasma Plasma Plasma Plasma

0.6 4 2 1-2 1 10 1.5 3.5 3.5

Forearm, palm - - - forearm, palm - forearm, palm - -

5 26 5-10 10 5 15-45 5 20 20

10-600 10-600 10-600 20-600 20-600 0-500 20-600 20-600 20-500

0.992 0.96-1.03 0.987 - 0.984 0.969 0.985 0.984 0.965

code Autocoding Autocoding Autocoding

20-70 20-60 30-55 25-60 30-55 30-60 30-60

6-44 14-40 10-40 10-35 6-44 10-35 12-42 4-30 15-40

10-70

Accu-chek Accu-chek Accu-chek Medisafe One-Touch One-Touch Precision MedisensePerforma Advantage II Active Mini Ultra Horizon QID Optium

Johnson & Johnson & Johnson &Johnson Johnson Johnson

()

()

(./.)

C, V, A, N C, V, A, N C, V, A, N C, V, A C C, V, A, N C C CCalibration Calibration Calibrationcode (button) code (button) code (button)

3 4 3

20-55 (>200) (%) 20-65 (

122 ..

1. Towfigh A, Romanova M, Weinreb JE, Munjas B, et al. Self-monitoring of bloodglucose levels in patients with type 2 diabetes mellitus not taking insulin: Ameta-analysis. Am J Manag Care 2008; 14: 468-75.

2. , , . : 1. , , . . 2548, 81-106.

123 ..

1.

1 2-5

2. 6 7 (hypoglycemia unawareness)8,9

3. 6

4. 10

1. (plasma glucose) 6,11 (venous blood) (anticoagulant) (plasma) (laboratory-based glucose measurement) glucose oxidase hexokinase

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

124 ..

12

3. (plasma glucose) (whole blood glucose) (International Federation of Clinical Chemistry IFCC) (adjusted plasma glucose)11 correction factor 1.11

adjusted plasma glucose = capillary whole blood glucose x 1.11

4. (falsely low) ( 3)

5. (HbA1c) 13,14 12

1. Cryer PE. Hypoglycemia, functional brain failure, and brain death. J Clin Invest 2007;117: 868870.

2. Laing SP, Swerdlow AJ, Slater SD, Botha JL, Burden AC, Waugh NR, et al. The BritishDiabetic Association Cohort Study, II: cause-specific mortality in patients withinsulin-treated diabetes mellitus. Diabet Med 1999; 16: 46671.

3. Gerstein HC, Miller ME, Byington RP, Goff Jr DC, Bigger JT, Buse JB, et al. Effects ofintensive glucose lowering in type 2 diabetes. The Action to Control CardiovascularRisk in Diabetes Study Group. N Engl J Med 2008; 358: 254559.

125 ..

4. Zoungas S, Patel A, Chalmers J, de Galan BE, Li Q, Billot L, Woodward M, et al. forthe ADVANCE Collaborative Group. Severe hypoglycemia and risks of vascular eventsand death. N Engl J Med 2010; 363:1410-8.

5. Desouza CV, Bolli GB, Fonseca V. Hypoglycemia, diabetes, and cardiovascular events.Diabetes Care. 2010;33:1389-94.

6. Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER, Service FJ.Evaluation and management of adult hypoglycemic disorders: an Endocrine SocietyClinical Practice Guideline. J Clin Endocrinol Metab 2009; 94: 70928.

7. Gold AE, MacLeod KM, Frier BM. Frequency of severe hypoglycemia in patients withtype I diabetes with impaired awareness of hypoglycemia. Diabetes Care 1994; 17:697703.

8. Dagogo-Jack SE, Craft S, Cryer PE. 1993 Hypoglycemia-associated autonomic failurein insulin-dependent diabetes mellitus. Recent antecedent hypoglycemia reducesautonomic responses to, symptoms of, and defense against subsequent hypoglycemia.J Clin Invest 1993; 91: 81928.

9. Segel SA, Paramore DS, Cryer PE. Hypoglycemia-associated autonomic failure inadvanced type 2 diabetes. Diabetes 2002; 51: 72433.

10. Cryer PE. Hypoglycaemia: the limiting factor in the glycaemic management of type Iand type II diabetes. Diabetologia 2002; 45: 93748.

11. DOrazio P, Burnett RW, Fogh-Andersen N, Jacobs E, Kuwa K, Wolf R. K?lpmann KK,et al. The International Federation of Clinical Chemistry Scientific Division WorkingGroup on selective electrodes and point of care testing. Approved IFCC Recommen-dation on reporting results for blood glucose (Abbreviated). Clinical Chemistry 2005;51: 9: 15736.

12. American Diabetes Association Workgroup on Hypoglycemia. Defining and reportinghypoglycemia in diabetes: a report from the American Diabetes Association Workgroupon Hypoglycemia. Diabetes Care 2005; 28: 1245-9.

13. The effect of intensive treatment of diabetes on the development and progression oflong-term complications in insulin-dependent diabetes mellitus. The DiabetesControl and Complications Trial Research Group. N Engl J Med 1993; 329: 97786.

14. Intensive blood-glucose control with sulphonylureas or insulin compared withconventional treatment and risk of complications in patients with type 2 diabetes(UKPDS33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352: 83753.

126 ..

127 ..

(eGFR) (eGFR) MDRD

()20 30 40 50 60 70 80

(./.)

ml/min/1.73 m2

0.6 > 90 > 90 > 90 > 90 > 90 > 90 > 900.7 > 90 > 90 > 90 > 90 > 90 88 860.8 > 90 90 84 81 78 75 730.9 85 78 74 70 68 66 641.0 75 69 65 62 60 58 571.1 67 62 58 56 54 52 511.2 61 56 53 51 49 47 461.3 56 51 48 46 44 43 421.4 51 47 44 42 41 40 381.5 47 43 41 39 38 36 351.6 44 40 38 36 35 34 331.7 41 38 35 34 33 32 311.8 38 35 33 32 31 30 291.9 36 33 31 30 29 28 272.0 34 31 29 28 27 26 252.1 32 29 28 26 26 25 242.2 30 28 26 25 24 23 232.3 29 26 25 24 23 22 222.4 27 25 24 23 22 21 212.5 26 24 23 22 21 20 202.6 25 23 22 21 20 19 192.7 24 22 21 20 19 19 182.8 23 21 20 19 18 18 172.9 22 20 19 18 18 17 163.0 21 19 18 18 17 16 163.1 20 19 18 17 16 16 153.2 20 18 17 16 16 15 153.3 19 17 16 16 15 15 143.4 18 17 16 15 15 14 143.5 18 16 15 15 14 14 133.6 17 16 15 14 14 13 133.7 17 15 14 14 13 13 133.8 16 15 14 13 13 12 123.9 16 14 14 13 12 12 124.0 15 14 13 13 12 12 114.1 15 14 13 12 12 11 114.2 14 13 12 12 11 11 11

128 ..

(eGFR) MDRD ()

20 30 40 50 60 70 80

(./.)0.8 > 90 > 90 > 90 > 90 > 90 > 90 > 900.9 > 90 > 90 > 90 > 90 > 90 89 861.0 > 90 > 90 88 84 81 79 761.1 > 90 84 79 75 73 70 681.2 82 76 71 68 66 64 621.3 75 69 65 62 60 58 561.4 69 63 60 57 55 53 521.5 63 58 55 53 51 49 481.6 59 54 51 49 47 46 441.7 55 51 48 46 44 43 411.8 51 47 45 43 41 40 391.9 48 44 42 40 39 37 362.0 46 42 40 38 36 35 342.1 43 40 37 36 34 33 322.2 41 38 35 34 33 32 312.3 39 36 34 32 31 30 292.4 37 34 32 31 29 29 282.5 35 32 31 29 28 27 272.6 34 31 29 28 27 26 252.7 32 30 28 27 26 25 242.8 31 28 27 26 25 24 232.9 30 27 26 25 24 23 223.0 28 26 25 24 23 22 223.1 27 25 24 23 22 21 213.2 26 24 23 22 21 21 203.3 26 24 22 21 20 20 193.4 25 23 21 20 20 19 193.5 24 22 21 20 19 18 183.6 23 21 20 19 18 18 173.7 22 21 19 19 18 17 173.8 22 20 19 18 17 17 163.9 21 19 18 17 17 16 164.0 20 19 18 17 16 16 154.1 20 18 17 16 16 15 154.2 19 18 17 16 15 15 154.3 19 17 16 16 15 15 144.4 18 17 16 15 15 14 144.5 18 16 16 15 14 14 134.6 17 16 15 14 14 13 134.7 17 16 15 14 14 13 134.8 17 15 14 14 13 13 134.9 16 15 14 13 13 13 125.0 16 15 14 13 13 12 125.1 15 14 13 13 12 12 125.2 15 14 13 13 12 12 115.3 15 14 13 12 12 11 115.4 14 13 12 12 11 11 115.5 14 13 12 12 11 11 115.6 14 13 12 12 11 11 10

129 ..

* 2

, , ,

( )

( ) velcro

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

130 ..

1

()

( )

131 ..

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) (reproducebility) *

monofilament 1. monofilament 2 (reusable)

(disposable) monofilament monofilament

*Klenerman L, McCabe C, Cogley D, Crerand S, Laing P, White M. Screening for patients at risk ofdiabetic foot ulceration in a general diabetic outpatient clinic. Diabet Med 1996; 13: 561-3

132 ..

2. monofilament

3. monofilament monofilament 2 monofilament

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

monofilament1. 4 metatarsalhead

1, 3 5

2. callus

monofilament 5.07 10 The American College of Physicians 2007

1. 2.

monofilament (forearm) monofilament 1-1.5

3.

Right Foot Left Foot

133 ..

4. 5. monofilament

monofilament 1-1.5 () monofilament monofilament monofilament

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

134 ..

The American College of Physicians 2007

1. 128 2. 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

135 ..

*

metatarsophalangeal 1

(

) 3/8 1 (forefoot)

metatarso-phalangeal joints (claw hammer toe)

velcro

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

136 ..

137 ..

*

/

(hemorrhagic callus)

( )

(Wagner grade)*

Grade 0 Pre-ulcerative lesions (healed ulcer, presence of bony deformity) Grade 1 Superficial ulcer without subcutaneous tissue involvement Grade 2 Penetration through the subcutaneous tissue (may expose bone,

tendon, ligament or joint capsule) Grade 3 Osteitis, abscess or osteomyelitis Grade 4 Gangrene of digit Grade 5 Gangrene of the foot requiring disarticulation

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

138 ..

**

callus granulation (claw hammer toe)

(intermittent claudication)

(rest pain) dorsalis pedis posterior tibial

( )

** . : , , . Diabetes Mellitus. 1. : 2548: 563-82

139 ..

*SEVERITY OF INFECTION MILD MODERATE SEVEREROUTES OF ADMINISTRATION P.O. P.O. I.V.Dicloxacillin or Clindamycin or Cefalexin Amoxycillin / Clavulanate or Co-trimoxazole Levofloxacin Ceftriaxone or Cefoxitin Ampicillin / Sulbactam Cefuroxime with or without metronidazole Ticarcillin / Clavulaniate Piperacillin / Tazobactam Ciprofloxacin or Levofloxacin + Clindamycin Imipenem / Cilastatin Vancomycin + Ceftazidime metronidazole

* Infectious Disease Society of America Guideline 2004P.O. = I.V. = =

*

SITE AND EXTENT ROUTE SETTING DURATIONOF INFECTIONS OF Rx OF Rx OF Rx

SOFT TISSUE ONLYMild T.C. / P.O. OPD 1-4 Moderate I.V. P.O. IPD / OPD 2-4 Severe I.V. P.O. IPD OPD 2-4

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

* Infectious Disease Society of America Guideline 2004T.C. = , P.O. = , I.V. = , IPD = inpatientdepartment, OPD = outpatient department

140 ..

141 ..

()

( ++)

4 / 1 2

G 32 0.5 . 1.0 . 2 4

( ++)

/

-

- - - , -

142 ..

- - - - -

- -

-

- - -

- -

/ - -

-

( ++) (networking)

- (PCU)

143 ..

-

call center hotline -

1-3

12

(regular insulin, RI)- (Actrapid HM, Humulin R, Gensulin R, Insugen R) 30-45 2-3 4-8 (Insulin IsophaneSuspension, NPH)- (Insulatard HM, Humulin N, Gensulin N, Insugen N) 2-4 4-8 10-16 - Pre-mixed 30% RI + 70% NPH (Mixtard 30 HM, 30-60 2 8 12-20

Humulin 70/30, Gensulin M30, Insugen 30/70)- Pre-mixed 50% RI + 50% NPH (Gensulin M50) 30-60 2 8 12-20 - Insulin lispro (Humalog) 5-15 1-2 3-4 - Insulin aspart (NovoRapid) 10-20 1-2 3-4 - Insulin glargine (Lantus) 2 24 - Insulin detemir (Levemir) 2 18-24 (Biphasic insulin analog)- Premixed 30% insulin aspart + 70% insulin aspart 10-20 1 8 12-20

protamine suspension (NovoMix 30)- Premixed 25% insulin lispro + 75% insulin lispro 10-20 1 8 12-20

protamine suspension (Humalog Mix 25)

()

144 ..

145 ..

diabetic ketoacidosis (DKA)1-4

1. DKA

(Kussmaul breathing metabolic acidosis) acetone (dehydration)

2. > 250 ./. (acidosis): serum bicarbonate (HCO3) < 18 /

arterial pH < 7.30 venous pH < 7.25 ketone

3. DKA 2

Mild DKA : arterial pH 7.25-7.30 HCO3 15-18 / Moderate DKA : arterial pH 7.00-7.24 HCO3 10-14 / Severe DKA : arterial pH < 7.00 HCO3 < 10 /

4. lactic acidosis alcoholic ketoacidosis, ingestion of drugs salicylate, methanol, ethylene glycol,paraldehyde chronic renal failure

11.

diabetic ketoacidosis

2.

glucose ketone serum electrolytes, BUN, Cr, Ca, PO4, CBC

146 ..

blood gas urine ketone monitor EKG lead II serum potassium

3. DKA flow sheet

body surface area electrolytes

2-4

4. 4.1 degree of dehydration1,2

- 7% dehydration: 17 mmol/l- 7-10% dehydration: 7-10% decreased

skin turgor, pH > 7.2, HCO3 > 10 mmol/l- 10-15% dehydration: 10-15%, capillary refill > 4 ,

pH < 7.2, HCO3 < 10 mmol/l shock 4.2 degree of dehydration

4.2.1 7% dehydration- 0.45% NaCl 3000 ml/m2/24 hr.- potassium (K): 40 mmol/l serum K 3.5

mmol/l K 60 mmol/l ( monitor EKG K 0.3 mmol/kg/hr) K K 6 mmol/l

4.2.2 7% dehydration- 0.9% NaCl 10 ml/kg 1/2

4.2.1- shock bolus 0.9% NaCl

5. DKA5.1 Intracranial complication

disorientation cerebral edema 24 cerebral edema mannitol 0.5-1 g/kg 20-30 cerebral edema water deficit 48 4000 ml/m2/24 hr hypotonic solution hypernatremia

147 ..

x 1.6

5.2 HCO31,2 HCO3 DKA severe acidosis

(HCO3 8 mmol/l pH 7.0) hypovolemic shock 0.9% NaCl bolus HCO3 HCO3

HCO3 (mmol) = 0.3 x BW (kg) x (10 - HCO3)

HCO3 10 mmol/l 2-4 HCO3 DKA

- serum osmolarity- overshoot alkalosis- K hypokalemia - cerebral edema, coma death - hypoxia shift oxyhemoglobin

dissociation curve5.3 Hypernatremic dehydration (corrected serum sodium > 150 mmol/l)

hyperglycemia serum sodium (Na) corrected Na

Corrected Na = Na (/) + blood glucose (./.) 100 100

corrected Na > 150 mmol/l hypernatremia hyper-osmolarity Na cerebral edema water deficit ( 72 ) 24 200-300 mg/dl Na 0.9% NaCl 2000ml/m2/24 hr

Na hypernatremia Na 10-15 mmol/l/24 hr

148 ..

2-48 1.

0.45% NaCl + 40 mmol/l of potassium (20 mmol/l of KCl + 20mmol/l of 2HPO4) 3000 ml/m

2/24 hr ( hypernatremia)2. (regular insulin)

2.1 regular insulin 100 units 0.9% NaCl 100 ml 1 ml = 1 unit

2.2 flush IV 30 ml2.3 infusion pump pediatric set

2.4 0.1 unit/kg/hr continuous infusion2.5 100 mg/dl/hr

3. Glucose infusion dextrose 300mg/dl 100 mg/dl/hr alteration of consciousness 5% 10% dextrose solutions 150-250 mg/dl

4. 4.1 glucose meter 1

4.2 serum electrolytes, Ca, PO4 2

4-6 acidosis5.

5.1 flow sheet

5.2 vital signs, fundi cerebraledema electrolytes

5.3 1.

1.1 HCO3 18 mmol/l 1.2

149 ..

2. 20-30 non-dextrose solutions dehydration

3. (subcutaneous insulin)3.1

3.2 regular insulin 0.25-0.5 unit/kg/dose

4-6 24 regular insulin (NPH) 0.7-1 unit/kg/day 1-1.5 unit/kg/day 2 3 ( NPH : regular insulin 2:1) 1 3 ( NPH : regular insulin 1:1)

1. . (Management fordiabetic ketoacidosis). 2545: 41 (1): 115-22.

2. Wolfsdort J, Craig ME, Daneman D, et al. Diabetes ketoacidosis in children andadolescents with diabetes: ISPAD clinical practice consensus guideline 2009. PediatricDiabetes 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.

4. Clinical Practice Guideline: Diabetic Ketoacidosis. . Available from http://www.ped.si.mahidol.ac.th/mdbtemplate/mytemplate/template.php?component=menu&qid=9

150 ..

151 ..

(Pre-gestational diabetes)1.

2 human chorionicsomato-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 serumcreatinine 3 ./

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

(congenital malformation) 9 HbA1c 9 macrosomia hyperinsulinemia intrauterine growth retardation (IUGR) (microangiopathy) uteroplacental insufficiency (intrauterine fetal death) lactate metabolic acidosis

respiratory distress syndrome hyperinsulinemia (hypocalcemia hypomagnesemia)

(Gestational diabetes mellitus) perinatal loss

(macrosomia, 4 ) hypoglycemia, hypocalcemia, polycythemia hyper-bilirubinemia macrosomia (obesity) (organogenesis)

1. . . : 2550. , , , . . 2550.

2. IDF Clinical Guidelines Task Force. Global Guideline on Pregnancy and Diabetes.International Diabetes Federation. Brussels, 2009.

152 ..