Churchill's Pocketbook of Diabetes Electronic, 2nd Edition
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CHURCHILL’S POCKETBOOKS
Diabetes
Second Edition
Sujoy Ghosh MD(General Medicine)
DM(Endocrinology) MRCP(UK) MRCPS(Glasgow)
Assistant Professor, Department of Endocrinology
and Metabolism, Institute of Post Graduate
Medical Education and Research, Calcutta, India
Andrew Collier BSc MD FRCP(Glasgow & Edinburgh)
Professor of Diabetes Care; Honorary Senior
Lecturer and Consultant Physician, University
Hospital Ayr, Ayr, UK
Foreword by
John Pickup BM BCh MA DPhil FRCPath
Professor of Diabetes and Metabolism, King’s College
London School of Medicine, Guy’s Hospital, London, UK
EDINBURGH LONDON NEW YORK OXFORD
PHILADELPHIA ST LOUIS SYDNEY TORONTO 2012
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First edition 2000
Second edition 2012
ISBN 978-0-443-10081-9
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
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CONTENTS
Foreword vii Smoking 77
Preface ix Alcohol 79
Abbreviations xi
3. Management of
diabetes 83
1. Diagnosis,
Type 1 diabetes – initiating
classification,
therapy 84
epidemiology and
Type 2 diabetes – initiating
biochemistry 1
therapy 97
The syndrome of diabetes Glycaemic monitoring 112
mellitus 2 Principles of education in
Classification of diabetes diabetes 116
mellitus 8 Organization of diabetes
Epidemiology 22 care 119
Metabolic syndrome 28
4. Acute metabolic
Haemochromatosis (’bronze
complications 127
diabetes’) 32
Polycystic ovary syndrome Hypoglycaemia 128
(PCOS) 36 Diabetic ketoacidosis 143
Biochemistry of diabetes 40 Diabetic hyperosmolar
Appendix 1.1: Prevalence non-ketotic syndrome –
estimates of diabetes, hyperosmolar
2010–2030 48 hyperglycaemic
syndrome 158
Lactic acidosis 161
2. Initial management and
education 51 5. Chronic
complications 165
Clinical presentation of
diabetes 52 Ocular complications 166
History and initial physical Diabetic neuropathy 178
examination 54 Diabetic foot disease 190
Screening for diabetes 58 Diabetic nephropathy
Who makes the diagnosis? 198
59 Diabetic cardiovascular
Initial management 59 disease 204
Influence of comorbidity 63 Dermatological features of
Lifestyle management 64 diabetes mellitus 219
Encouraging dietary change Musculoskeletal and
in clinical practice 71 connective tissue
Exercise and physical disease 222
activity 74 Infection and diabetes 224
CONTENTS
vi
s
6. Special topics 227 Psychosocial and legal
aspects 276
Childhood and
Appendix 6.1: Principles of
adolescence 228
dietary planning in
Diabetes in the elderly 237
children with diabetes 284
Management of diabetes in
Appendix 6.2: Checklist for
women of childbearing
provision of information to
age 240
women with GDM 285
Surgery and diabetes 255
Intercurrent illnesses 267 References, Bibliography
Bariatric surgery 268 and Further
Male and female sexual Reading 287
dysfunction 270 Index 307
FOREWORD
The practice and the science of diabetes, and the patients who suffer
from this disease, have never remained the same. When I was
beginning to learn about diabetes at medical school, about 40 years
ago, insulin was of course extracted from animal pancreases (though
highly purified, ‘monocomponent’ insulin was being introduced at
that time). Glass syringes and needles had to boiled to sterilize them
and monitoring of diabetes control was by urine testing. Beds on the
medical ward were frequently occupied by diabetic patients, many
with gangrenous feet. Within just a decade, when I was well into
my career as a diabetologist, injected insulin was of human sequence
and made by semi-synthesis or recombinant DNA technology,
disposable plastic syringes and needles had been introduced (after a
long fight), insulin ‘pens’ were appearing and even insulin pumps had
been in use for five years. Patients monitored their own metabolic
control using capillary blood samples and portable meters and not
by urine testing. Type 2 diabetes was no longer called ‘mild diabetes’,
though we thought it was a disease of the middle aged and elderly.
Change in diabetes has shown no signs of diminishing in the last
decade, and in fact it is accelerating. Scientific advances in the
understanding of diabetes and its complications are being translated
into improved clinical practice at ever faster rates. But the increasing
prevalence, costs and human suffering associated with diabetes have
produced a global health nightmare which challenges us to do better –
in public health, scientific and clinical research, clinical care and
social policy.
What has changed recently? The relentless increase in obesity and
inactivity amongst all age groups has caused the emergence of this
type of diabetes in children and adolescents, as well as adults. Type 2
diabetes is now increasingly recognised as a disorder of the immune
system, though it seems to be a disease of activated innate immunity.
Rapid- and long-acting insulin analogues are now the insulins of
choice for many people with diabetes, and newer insulins are just
around the corner – analogues with even longer duration for better
basal replacement, and rapid-acting formulations with even faster
absorption for meal-time use. New technologies such as smart
insulin pumps and continuous glucose monitoring are playing an
increasing part in the management of selected patients with type 1
diabetes and sub-optimal glycaemic control. In type 2 diabetes, new
blood glucose-lowering drugs such as gliptins and GLP-1 agonists
are proving effective, and in the grossly obese patient with diabetes,
bariatric surgery is becoming a recognised treatment option. In the
everyday diabetes clinic, management of hypertension and lipids are
FOREWORD
viii
s
now seen as being as integral to diabetes care as blood glucose
control. And many more advances could be mentioned.
Diabetes is common, costly, complex and constantly changing.
There is much to learn. The management of people with diabetes
is not the same today as it was even a few years ago. Sujoy Ghosh
and Andrew Collier have produced in this book a clear, up-to-date
guide to modern diabetes and its management that will help all
practitioners. I am sure it will make a substantial contribution both
to our understanding of diabetes and to improving the care of the
patients who suffer from it.
London 2012 John Pickup
PREFACE
The incidence of diabetes is increasing at epidemic proportions
worldwide. The first Pocketbook of Diabetes was published in 2000
and the structure of this edition follows similar lines. However,
diabetes expertise has moved on considerably, with greater
understanding of aetiopathogenesis of the different types of diabetes,
the emerging roles of novel pharmacological agents, and the
importance of multidisciplinary team working and multi-risk-factor
treatment.
Re-writing this book was easy and difficult at the same time. Our
predecessor, Professor Andrew Krentz, who wrote the previous
edition, had done a wonderful job and hence it was incredibly
difficult to improve upon his work. At the same time his work
provided us with a platform to update the book, keeping in view the
advances in knowledge.
The emphasis of this book is on clinical management and the aim
has been to provide a balanced view of current clinical practice. This
book is not meant to be an alternative to time tested exhaustive
text-books on diabetes. This pocketbook is meant to be a be a
concise companion for all health professionals involved in
diabetes management, providing easily accessible information and
guidance.
Finally no words of praise are enough for the constant help and
support that we received from our publishers, especially Sheila
Black, for bearing with the unbearable!
Calcutta and Ayr, 2012 Sujoy Ghosh
Andrew Collier
Intentionally left as blank
ABBREVIATIONS
4 S Scandinavian Simvastatin ATP adenosine triphosphate
Study BDI Beck Depression
AAP atypical antipsychotic Inventory
ABPI ankle : brachial pressure BERTIE Bournemouth Type 1
index Intensive Education
AC abdominal circumference BGAT Blood Glucose
ACCORD Action to Control Awareness Training
Cardiovascular Risk in BHS British Hypertension
Diabetes Society
ACE angiotensin converting BITES Brief Intervention in
enzyme Type 1 Diabetes – Education
ACR albumin/creatinine ratio for Self-efficacy
ACT acceptance and BMD bone mineral density
commitment therapy BMI body mass index
ADA American Diabetes BMS bare metal stents
Association BNF British National
ADOPT A Diabetes Outcome Formulary
Progression Trial BP blood pressure
ADVANCE Action in Diabetes BSA body surface area
and Vascular Disease:
Preterax and Diamicron MR BUN blood urea nitrogen
Controlled Evaluation CABG coronary artery bypass
AED antiepileptic drug grafting
AER albumin excretion rate CAPD continuous ambulatory
peritoneal dialysis
ALLHAT Antihypertensive
and Lipid-Lowering CARDS Collaborative
Treatment to Prevent Heart Atorvastatin Diabetes Study
Attack Trial CARE Cholesterol and
ARB angiotensin receptor Recurrent Events
blocker CBT cognitive behavioural
ARI aldose reduction inhibitor therapy
ASCOT Anglo-Scandinavian CCB calcium channel blocker
Cardiac Outcomes Trial CES-D Centre for
ASH alcoholic steatohepatitis Epidemiological Studies –
Depression Scale
ASSIGN Assessing
cardiovascular risk using cGMP cyclic guanosine
SIGN guidelines to assign monophosphate
preventive treatment CHD coronary heart disease
ABBREVIATIONS
xii
s
CHF congestive heart failure DPP dipeptidyl peptidase
CI confidence interval DR diabetic retinopathy
CKD chronic kidney disease DRS Diabetic Retinopathy
CMG continuous monitoring Study
of interstitial glucose DSME diabetes self-
CoA coenzyme A management education
COC combined oral DVLA Driver and Vehicle
contraceptive Licensing Agency
COPD chronic obstructive ED erectile dysfunction
pulmonary disease EDHF endothelium-derived
CRP C-reactive protein hyperpolarizing factor
CSI continuous subcutaneous ER endoplasmic reticulum
insulin infusion ESRD end-stage renal disease
CSMO clinically significant FDA Food and Drug
macular oedema Administration
CT computed tomography FFA fundus fluorescein
CTG cardiotocography angiography
CVD cardiovascular disease FIELD Fenofibrate
Intervention and Event
DAFNE Dose Adjustment for
Lowering in Diabetes
Normal Eating
FLD fatty liver disease
DCCT Diabetes Control and
Complications Trial FPG fasting plasma glucose
DES drug-eluting stents FSH follicle-stimulating
hormone
DESMOND Diabetes
Education and Self- GA3P glyceraldehyde
Management for Ongoing 3-phosphate
and Newly Diagnosed GAD glutamic acid
DHAP dihydroxy dehydrogenase
acetonephosphate GDM gestational diabetes
DIGAMI Diabetes mellitus, mellitus
Insulin-Glucose infusion in GFR glomerular filtration rate
Acute Myocardial Infarction GHbSD standard deviations of
DISH diffuse idiopathic glycosylated haemoglobin
skeletal hyperostosis GI glycaemic index
DISN diabetes inpatient GIP glucose-dependent
specialist nurse insulinotropic peptide
DKA diabetic ketoacidosis GLP-1 glucagon-like peptide-1
ABBREVIATIONS
xiii
s
GLUT glucose transporter IFG impaired fasting glucose
GnRH gonadotropin-releasing IGT impaired glucose
hormone tolerance
GP general practitioner IPF insulin promoter factor
HAATT Hypoglycaemia IPPV intermittent postive-
Anticipation, Awareness and pressure ventilation
Treatment Training IRMA intraretinal
HADS Hospital Anxiety and microvascular anomaly
Depression Scale IRS insulin receptor substrate
HAPO Hyperglycaemia and IUD intrauterine device
Adverse Pregnancy Outcome
IUGR intrauterine growth
HbA1c glycated haemoglobin restriction
HDL high density lipoprotein IUS intrauterine systems
HF heart failure IV intravenous
HHS hyperosmolar JBS 2 Joint British Societies’
hyperglycaemic state guideline
HIV human immunodeficiency LADA latent autoimmune
virus diabetes in adults
HLA human leukocyte antigen LCD low calorie diet
HNF hepatocyte nuclear factor LDL low density lipoprotein
HOMA homeostasis model LED low energy diets
assessment
LH luteinizing hormone
HONK hyperosmolar non-
ketotic (coma) LVSD left ventricular systolic
dysfunction
HOPE Heart Outcomes
Prevention Evaluation MDI multiple daily injections
HOT Hypertension Optimal MDRD Modification of Diet
Treatment in Renal Disease
HPS Heart Protection Study MELAS mitochondrial
myopathy, encephalopathy,
HR hazard ratio lactic acidosis and stroke-like
HTA Health Technology MI myocardial infarction
Assessment
MNT medical nutrition
IDF International Diabetes therapy
Federation
MODY maturity-onset
IFCC International Federation diabetes of the young
of Clinical Chemistry and
MR modified release
Laboratory Medicine
ABBREVIATIONS
xiv
s
MRI magnetic resonance PCR protein/creatinine ratio
imaging PCT porphyria cutanea tarda
NAD nicotinamide adenine PDR poliferative diabetic
dinucleotide retinopathy
NASH non-alcoholic PHQ Patient Health
steatohepatitis Questionnaire
NCEP National Cholesterol PPR peroxisome proliferator-
Education Program activated receptor
NDH non-diabetic PROactive PROspective
hyperglycaemia pioglitAzone Clinical Trial In
NGSP National macroVascular Events
Glycohemoglobin PUFA omega-3
Standardization Program polyunsaturated fatty acids
NHS QIS NHS Quality PVD peripheral vascular
Improvement Scotland disease
NICE National Institute for QALY quality-adjusted life
Health and Clinical year
Excellence
QOF quality outcomes
NPDR non-proliferative framework
diabetic retinopathy
QoL quality of life
NPH neutral protamine
Hagedorm QUICKI quantitative insulin
sensitivity check index
NPWT negative pressure
RAAS renin–angiotensin–
wound therapy
aldosterone system
NYHA New York Heart
Association (classification) RARS refractory anaemia with
ringed sideroblasts
OCT optical coherence
tomography RCT randomized controlled
trial
OGTT oral glucose tolerance
test RR relative risk
RRT renal replacement
OR odds ratio
therapy
PAD peripheral arterial disease
SBP systolic blood pressure
PAID Problem Areas in
SCID Structured Clinical
Diabetes
Interview for DSM-IV-TR
PCI percutaneous coronary
SD standard deviation
intervention
SE standard error
PCOS polycystic ovary
syndrome SGA small for gestational age
ABBREVIATIONS
xv
s
SGLT sodium–glucose co- TCA tricyclic antidepressant
transporter inhibitor TG triglycerides
SHBG sex hormone-binding TSH thyroid-stimulating
globulin hormone
SIGN Scottish Intercollegiate TZD thiazolidinedione
Guidelines Network
UGDP University Group
SMBG self-monitoring of Diabetes Program
blood glucose
UKPDS UK Prospective
SMD standardized mean Diabetes Study
difference
VADT Veterans Affairs
SMUG self-monitoring of Diabetes Trial
urine glucose
VEGF vascular endothelial
SREBP sterol regulatory growth factor
element-binding protein
VLCD very low calorie diet
SSRI selective serotonin
VLED very low energy diet
reuptake inhibitor
SU sulphonylurea WHO World Health
Organization
Intentionally left as blank
