​Guidelines for diagnosis and treatment of type 2 diabetes for travelers

I. Concept
Diabetes is a chronic disorder, which has the following attributes:
1. Increased blood glucose;
2. Combined with abnormalities in carbohydrate, lipid and protein metabolism;
3. The disease is always associated with the tendency to develop kidney, eye, neurological and other cardiovascular diseases.

II. Causes - Pathogenesis and complications
1. Cause
The most important feature in the pathophysiology of type 2 diabetes is the interaction between genetic and environmental factors.
a) Genetic factors.
b) Environmental factors: this is a group of factors that can be intervened to reduce the incidence of disease. These factors are:
- Lifestyle changes: such as reducing physical activity; changing diet towards increasing starch and reducing fiber causing excess energy.
- Food quality.
- Stress.
c) As life expectancy increases, the risk of disease increases: This is an uncontrollable factor.
2. Pathogenesis
Beta cell dysfunction and insulin resistance
a) Overweight, obesity, and physical inactivity are common characteristics in people with type 2 diabetes and insulin resistance. Hyperinsulinemia and insulin resistance are also found in people with prediabetes, essential hypertension, and metabolic syndrome.
b) People with type 2 diabetes, in addition to insulin resistance, also have insulin deficiency - especially when fasting plasma glucose is above 10.0 mmol/L.
3. Complications of the disease
The characteristics of complications of type 2 diabetes are closely related to the process of disease development. Therefore, at the time of clinical detection of the disease, the physician must look for complications of the disease. Regarding the classification of complications, it is possible to divide them into acute and chronic complications. In chronic complications, it is divided into large blood vessel complications and small blood vessel complications.

III. Diagnosis and classification of diabetes
1. Diagnosis
a) Early diagnosis of type 2 diabetes: Subjects with risk factors for screening for type 2 diabetes: Age ≥ 45 and have one of the following risk factors:
- BMI ≥ 23 (see Appendix 1: Diagnostic criteria for overweight and obesity based on BMI and waist circumference applied to adults in Asia (according to IDF, 2005)
- Blood pressure above 130/85 mmHg
- Having a family member with diabetes in the next generation (father, mother, brother, sister, or child with type 2 diabetes).
- History of diagnosis of metabolic syndrome, prediabetes (impaired fasting glucose tolerance, impaired glucose tolerance).
- Women with special pregnancy history (gestational diabetes, giving birth to a large baby - weighing over 3600 grams, multiple spontaneous miscarriages, stillbirth).
- People with lipid disorders; especially when HDL-c is below 0.9 mmol/L and Triglycride is above 2.2 mmol/l.
b) Diagnosis of prediabetes.
- Impaired glucose tolerance (IGT), if the plasma glucose level at 2 hours after an oral glucose tolerance test is from 7.8 mmol/l (140 mg/dl) to 11.0 mmol/l (200 mg/dl).
- Impaired fasting glucose (IFG), if fasting plasma glucose (8 hours after eating) is from 6.1 mmol/l (110 mg/dl) to 6.9 mmol/l (125 mg/dl) and plasma glucose at 2 hours of the hyperglycemia test is below 7.8 mmol/l (< 140 mg/dl).
c) Diagnosis of diabetes: Diabetes diagnosis criteria (WHO-1999), based on one of 3 criteria:
- Fasting plasma glucose level ≥ 7.0 mmol/l (≥ 126 mg/dl).
- Plasma glucose level ≥ 11.1 mmol/l (200 mg/dl) at 2 hours after oral glucose tolerance test.
- Have symptoms of diabetes (clinical); plasma glucose level at any time ≥ 11.1 mmol/l (200 mg/dl).
Points to note:
- If the diagnosis is based on fasting plasma glucose and/or an oral glucose tolerance test, it must be performed twice on two different days.
- There are cases where diabetes is diagnosed but fasting plasma glucose is normal. In these special cases, the method of diagnosis must be clearly stated. For example, "Type 2 diabetes - Oral glucose tolerance test".
2. Classification of diabetes (Simple classification).
a) Type 1 diabetes: Is the result of the destruction of beta cells of the islets of pancreas. The consequence is the need to use exogenous insulin to maintain metabolism, prevent ketoacidosis which can cause coma and death.
b) Type 2 diabetes.
c) Other special forms.
- Beta cell dysfunction, reduced insulin activity due to genes.
- Pathology of the exocrine pancreas.
- Due to other endocrine diseases.
- Caused by drugs or other chemicals.
- Caused by infection.
- Rare forms, genetic syndromes.
d) Gestational diabetes.
Procedure for performing diagnostic tests for type 2 diabetes (WHO-2011)
 
Note: DHLĐ- Fasting blood sugar, DHBK- Random blood sugar, DH2H- Blood sugar 2 hours after drinking 75g glucose, OGTT- Oral glucose tolerance test, SGĐHLĐ- Impaired fasting blood sugar, RLDNG- Impaired glucose tolerance, DTĐ- Diabetes mellitus.
* Reconfirm diagnosis if initial fasting blood sugar is 5.5-6.9 mmol/l or random blood sugar is 5.5-11.0 mmol/l.
** If fasting plasma glucose is below 7.0 mmol/l, perform a hyperglycemic test. If blood glucose is 7.0 mmol/l or higher, diabetes is diagnosed.
# People whose initial blood sugar level is consistent with a diagnosis of diabetes or LDH/LDL but is not re-determined will have to be re-tested after 1 year and the next test will be determined based on the test results after 1 year.

IV. Treatment of type 2 diabetes
These treatment guidelines apply only to people with type 2 diabetes who are not experiencing acute illnesses, such as heart attack, acute infection, or surgery, or cancer.
This treatment guideline does not apply to people under 18 years of age with type 2 diabetes.
1. General principles:
a) Purpose:
- Maintain fasting blood glucose and postprandial blood glucose levels close to physiological levels, achieve ideal HbA1c levels, to reduce related complications and reduce mortality due to diabetes.
- Lose weight (for overweight or obese people) or maintain a healthy weight.
b) Principle:
- Medication must be combined with diet and exercise. This is the trio of methods for treating diabetes.
- Must combine treatment to lower blood glucose, adjust lipid disorders, maintain reasonable blood pressure measurements, and prevent and combat blood clotting disorders.
- When insulin is needed (such as in acute attacks of chronic diseases, infections, myocardial infarction, cancer, surgery).
2. Treatment goals

Index

Unit

Good

Accept

Least

Blood glucose
- When hungry
- After eating

mmol/l

 
4.4 – 6.1
4.4 – 7.8

 
6.2 – 7.0
7.8 ≤ 10.0

 
> 7.0
> 10.0

HbA1c

%

≤ 6.5

> 6.5 to ≤ 7.5

> 7.5

Blood pressure

mm Hg

≤ 130/80*

130/80 - 140/90

> 140/90

BMI

kg/(m)2

18.5 - 23

18.5 - 23

≥ 23

TP Cholesterol

mmol/l

< 4.5

4.5 - ≤ 5.2

≥ 5.3

HDL-c

mmol/l

> 1.1

≥ 0.9

< 0.9

Triglyceride

mmol/l

1.5

1.5 - ≤ 2.2

> 2.2

LDL-c

mmol/l

< 2.5**

2.5 - 3.4

≥ 3.4

Non-HDL

mmol/l

3.4

3.4 - 4.1

> 4.1

* People with kidney complications - from microalbuminuria level HA ≤ 125/75.
** People with cardiovascular damage LDL-c should be below 1.7 mmol/l (below 70 mg/dl).
3. Choice of drugs and treatment methods
The treatment goal must be to quickly bring blood glucose levels to the best management level, achieving the goal of bringing HbA1C to between 6.5 and 7.0% within 3 months. Do not apply the stepwise treatment method but use combination drugs early. Specifically
- If HbA1c is above 9.0% and fasting plasma glucose level is above 13.0 mmol/l, two types of combined hypoglycemic tablets can be prescribed.
- If HbA1C is above 9.0% and fasting blood glucose is above 15.0 mmol/l, insulin may be prescribed immediately.
- In addition to regulating blood glucose levels, it is necessary to simultaneously pay attention to balancing blood lipid components, blood clotting parameters, maintaining blood pressure measurements...
- Monitor and evaluate blood glucose control including fasting blood glucose, postprandial blood glucose, especially HbA1c level - measured every 3 to 6 months.
- Physicians must have a good understanding of how to use oral hypoglycemic drugs, use insulin, how to combine drugs in treatment, and special notes on the patient's condition when treating diabetes.
- For medical facilities that do not perform HbA1c testing, evaluate based on average plasma glucose level (See Appendix 3: Relationship between average plasma glucose and HbA1c).
a) Drug selection and drug combination
- Refer to the American Diabetes Association's guidelines for drug selection and drug combinations.
- See Appendix 2: Drugs for the treatment of type 2 diabetes.
 
Things to note when choosing medicine
- Must comply with the principles of treatment of type 2 diabetes, section 2 (Choice of drugs and treatment methods);
- Based on the clinical examination of each patient, the treatment method is decided. In cases where the disease is newly diagnosed, the blood glucose level is low, and there are no complications, it should be adjusted by diet, exercise, and closely monitored for 3-6 months; if the treatment goal is not achieved, medication should be considered.
- The initial drug choice for monotherapy should be based on body mass index (BMI). If BMI is below 23, sulfonyl urea should be chosen. If BMI is 23 or higher, metformin should be chosen.
- Steps 1, 2, and 3 can be combined with drugs in the alphaglucosidase inhibitor group.
b) Principles of insulin use when combining insulin and oral hypoglycemic drugs.
About one-third of people with type 2 diabetes are required to use insulin to maintain stable blood glucose levels. This proportion will increase as the duration of the disease increases. Maintaining blood glucose levels close to physiological levels has been shown to be the best way to prevent vascular disease, reduce mortality, prolong life and improve the quality of life of people with diabetes.
- It is necessary to explain to the patient to understand and feel secure with the combined treatment method with insulin, and instruct the patient on how to self-monitor when using insulin.
- Choose an injection pen or syringe that is suitable for the type of insulin (1ml = 100 units or 1ml = 40 units; 1ml = 50 units of insulin).
Indications for insulin use:
- Insulin may be prescribed at the first visit if the HbA1C level is above 9.0% and the fasting blood glucose level is above 15.0 mmol/l.
- People with diabetes but are suffering from another acute illness; for example, severe infection, myocardial infarction, stroke...
- Diabetic patients with kidney failure are contraindicated to use blood glucose lowering pills; patients with liver damage...
- People with diabetes during pregnancy or gestational diabetes.
- People who are not effectively treated with oral hypoglycemic drugs; people who are allergic to oral hypoglycemic drugs...
Starting insulin:Usually the sulfonylurea dose is reduced by 50% and taken only in the morning.
- Insulin dose usually starts with a dose of 0.1 IU/kg NPH type, injected before bedtime or
- Two injections per day with mixed insulin (insulin mixt), depending on plasma glucose and/or HbA1c levels.
Adjusting insulin dose:
- When the sulfonylurea dose is increased to the maximum level or insulin therapy reaches 0.3 IU/kg but still does not lower blood sugar.
- Adjust insulin dose every 3-4 days or 2 times/week.
4. Treatment of diabetes at the glands
General principles: Treatment referral guidelines are applied nationwide. Depending on the conditions of the treatment facility (in terms of human resources and facilities), the head of the medical facility can decide on the level of intervention and referral.
a) Commune - ward route
If there is an internist who can treat diabetic patients, especially mild and moderate cases. Specifically, the fasting blood glucose level is below 10.0 mmol/l and/or HbA1C is below 8.0%. When the fasting blood glucose level is above 10.0 mmol/l, it must be transferred immediately to the district level.
No doctor had to transfer immediately to a higher level.
b) At district level:
If the fasting blood glucose level is from 10.0 mmol/l or higher to less than 13.0 mmol/l; HbA1c is less than 9.0% and the patient does not have any serious complications (eg foot or cardiovascular complications), the patient can be treated at the district level.
Refer to the above line if one of the following conditions exists:
- Fasting blood plasma glucose above 13.0 mmol/l and/or HbA1C above 9.0%.
- Patients with severe cardiovascular complications (myocardial ischemia, myocardial infarction), diabetic foot, kidney complications.
- There are signs of acute complications, first aid must be performed and the patient transferred to a higher level as soon as possible.
- Active treatment but after 3 months still not achieving blood glucose management targets.
c) Provincial route:
As the last line of the locality, we must strive to treat the disease comprehensively. Transfer to another facility when one of the following conditions occurs:
- The disease has serious complications beyond the ability to intervene.
- After 6 months of treatment, treatment goals have not been achieved.

V. Progression and complications
1. Progress:
Type 2 diabetes is a progressive disease. Complications develop over time.
2. Complications:
a) Acute complications:
- Ketoacidosis coma
- Lower blood glucose
- Hyperglycemic coma without ketoacidosis
- Lactic acidosis coma
- Acute infections.
* Ketoacidosis coma:
This is an immediate life-threatening complication caused by a lack of insulin, which causes severe disorders in protein, lipid and carbohydrate metabolism. This is an internal medical emergency that needs to be monitored in intensive care units.
Favorable factors:
Ketoacidosis often occurs for no apparent reason, but it is more likely to occur if a person with type 1 diabetes also has:
- Infections such as pneumonia, meningitis, gastrointestinal infections, urinary tract infections, flu, etc.
- Trauma: Including mental stress.
- Myocardial infarction, stroke.
- Use of drugs containing cocaine.
- Using hypoglycemic drugs without proper indications and dosage.
- Use corticosteroids.
Clinical symptoms and signs
Symptoms:
- Nausea and vomiting
- Thirsty, drinks a lot and urinates a lot
- Fatigue and/or loss of appetite.
- Stomach-ache
- Blurred vision
- Symptoms of consciousness such as drowsiness, dreaming
Token:
- Rapid heart rate
- Lower blood pressure
- Dehydration
- Hot dry skin
- Kusmaul breathing
- Impaired consciousness and/or coma
- Breath smells like ketones
- Weight loss
Paraclinical:
- Arterial blood pH < 7.2
- Bicarbonate (plasma) < 15mEq/l or 15 mmol/l)
- Blood glucose > 13.9 mmol/l.
- Increased blood ketones, positive urine ketones
Follow-up and treatment
Purpose:
- Eliminate factors that endanger the patient's life.
- Prevent dehydration, compensate for insulin levels, balance electrolytes, acid-base.
Metrics to watch
Clinical monitoring:
- Mental status 1 hour/time
- Vital signs (temperature, pulse, blood pressure, breathing rate) every 1 hour
- Weight (if possible).
Paraclinical monitoring:
- Electrocardiogram
- Blood glucose (at bed) 1 hour/1 time
- Blood potassium, pH 1 ÷ 2 hours/1 time
- Na+, Cl-, Bicarbonate 2 ÷ 4 hours/1 time
- Phosphate, magnesium 4 - 6 hours/1 time
- Urea or creatinine every 4 - 6 hours
- Ketoneuria 2 - 4 hours
- Blood calcium: as prescribed
- Hematocrit: as prescribed
Other tests (if needed): blood culture; urine culture, cytology, blood count, with special attention to white blood cell count; blood amylase; lipid metabolism disorders, gastric aspiration for testing; blood ketones.
Treatment monitoring
- Fluid input and output 1 to 4 hours/time
- Insulin infusion volume (units/hour) 1 to 4 hours/1 time
- Potassium (mmol/l/h) 1 to 4 hours/1 time
- Plasma glucose (mmol/l) 1 to 4 hours/1 time
- Bicarbonate and phosphate 1 to 4 hours/1 time.
Treatment - first aid: Usually use intravenous insulin
- Initial dose from 0.1 - 0.15 IU/kg/h (intravenous injection) or
- Intravenous infusion at a dose and rate of 0.1 IU/kg/h
- Move up the line.
Linearity:Treatment of ketoacidosis should be performed in emergency centers.
- Ward and commune level first aid and transfer immediately to district level.
- District level prescribes IV fluids, insulin infusion and transfers to higher level.
Prevent:Diabetic ketoacidosis can be prevented by educating the patient and providing medical care.
For patients:
- Know how to self-monitor blood glucose and urine ketones.
- Contact your doctor immediately if you have another illness, or if you experience unusual symptoms such as nausea, fever, abdominal pain, diarrhea, or high blood glucose levels, persistent ketones in urine, etc. These are warning signs of possible ketoacidosis.
- Never reduce your insulin dose or stop taking your medication on your own, even if you have another illness.
With doctor.
- Inform patients about their health status, how to detect symptoms or dangerous signs that require medical examination.
- When examining, be meticulous to detect any abnormal developments of the disease. Classify patients according to the stage of the disease to have an appropriate care plan.
* Lower blood glucose
Common causes:
- Increase insulin secretion (a substance that inhibits glucose production in the liver and stimulates glucose consumption in skeletal muscle and adipose tissue)
- Reduced food intake (due to strict diet or malabsorption problems).
- Increase exercise intensity (increases glucose utilization in skeletal muscle)
Clinical and paraclinical symptoms: Clinical hypoglycemia often occurs when:
- Biochemistry: Fasting plasma glucose concentration < 2.8 mmol/l (50 mg/dl) is severe hypoglycemia, and when blood glucose level < 3.9 mmol/l (< 70 mg/dl) is considered to have started hypoglycemia. It should also be noted that in young patients, there is a tendency for clinical manifestations at higher plasma glucose levels (3.8 mmol/l = 68 mg/dl) than in adults (3.1 mmol/l = 56 mg/dl).
- Clinical: Divided into 3 levels:
+ Mild level: Usually symptoms include sweating, shaking hands and feet, and hunger. These are symptoms of the autonomic nervous system. These symptoms will disappear after drinking 10-15 grams of carbohydrates, from 10-15 minutes. At this level, the patient can self-treat.
+ Moderate level: At this level, the clinical manifestations include both autonomic nervous system and neurological signs of reduced tissue glucose such as: headache, behavioral changes, irritability, decreased attention, drowsiness. If not intervened promptly, the patient will quickly progress to a severe level.
+ Severe level: At this time, blood glucose levels drop very low. Clinical manifestations include coma, loss of sensation or convulsions. Emergency treatment at this time requires intravenous glucose and/or glucagon.
Treatment of hypoglycemia
- For mild cases: Just 10-15g of Carbohydrates taken orally will quickly return blood glucose to normal. Do not use Chocolate and ice cream to treat acute hypoglycemia, because the amount of fat in these foods will limit sugar absorption and will also be a factor in weight gain.
- In case the patient is walking on the road or driving a vehicle and shows signs of low blood glucose, he/she must stop for 10-15 minutes and wait until blood glucose returns to normal before continuing work.
- Moderate: Oral intervention is possible, but it takes longer and higher doses to return blood glucose to normal. Glucagon can be injected intramuscularly or subcutaneously in combination with oral administration.
- Severe hypoglycemia: Because the patient is unconscious and unable to swallow, giving them something to drink may cause them to choke on their airway. These patients must use intravenous glucagon and hypertonic glucose infusion:
Glucagon
- Glucagon dose needed to treat moderate or severe hypoglycemia: The usual dose is 1 mg.
- Route of administration: Can be injected subcutaneously, intramuscularly or intravenously.
- How to use glucagon must be instructed to the patient's relatives, even to the landlord or hotel staff so that they can use it in emergency situations.
Intravenous glucose:This is the most basic treatment if medical staff is available. In severe cases of hypoglycemia, intravenous glucose combined with glucagon is considered the most perfect emergency method. Usually when starting emergency treatment, people often use:
+ 10 - 25g (in 50% Dextrose solution) intravenous injection
+ 50 - 100ml 30% glucose solution
+ Time to perform first aid is from 1 - 3 minutes.
+ The next emergency dose depends on the patient's response. Usually intravenous glucose is given at a dose of 5 - 10 g/hour. Glucose will be continued until the patient fully recovers and is able to eat and drink on his own.
Prevent hypoglycemia.Is the room the causes:
- Causes related to insulin use
+ Due to overdose
+ Time of use is not suitable for meals or type of insulin is not suitable, injecting insulin but skipping meals.
+ Intensive insulin therapy
+ Abnormal insulin absorption at the injection site: Absorption is faster if injected in an area of frequent movement, injection site has problems: subcutaneous fat atrophy or dystrophy at the injection site.
+ Using more pure insulin or changing from synthetic to mixed insulin or human insulin changes the rate of absorption.
+ Strict diet: Eat little, inappropriate time between meals
+ Wrong practice: No plan, inappropriate practice level and time.
+ Drinking alcohol and using it in combination with certain medications
Linearity:Emergency treatment for hypoglycemic coma must be widely disseminated, educated, and disseminated not only to medical staff but also to those who have many opportunities to communicate with patients.
- Ward, commune and equivalent lines:
+ Emergency treatment for people in coma with mild and moderate hypoglycemia.
+ First aid for people in a coma with severe hypoglycemia.
- District level: Must be able to provide emergency care to people in a coma with severe hypoglycemia.
* Hyperglycemic coma without ketoacidosis(Hyperosmolar Coma - HMTALTT)
Characteristic:Common in people with type 2 diabetes over 60 years old, more common in women than men.
- The disease has a poor prognosis, high mortality rate even when treated in emergency centers with full facilities and good specialists. If patients survive, they often leave sequelae.
- Non-ketoacidotic hyperglycemia can occur in people who have never been diagnosed with type 2 diabetes.
- There are many similarities to ketoacidosis coma. The main differences are hyperglycemia, dehydration, and electrolyte disturbances.
- The important feature to distinguish from ketoacidosis coma is the absence or very slight presence of ketone bodies in the urine.
Causes and favorable factors:Factors favoring the development of non-ketoacidotic hyperglycemic coma.

Drugs used

Treatment process

Chronic disease

Acute illness

Glucocorticoids
Diuretic
Diphenylhydantoin
Alpha-Adrenergic Blockers
Diazoxide
L-asparaginase
Immunosuppressants.

Peritoneal dialysis
Hemodialysis
Surgical stress.
Infuse more glucose.
After surgery

Kidney disease
Heart disease
Hypertension
Stroke
Drink alcohol
Mental illness
Loss of thirst

Infection
Urinary tract infection
Potholes
Sepsis
Gastrointestinal bleeding
Stroke
Myocardial infarction
Acute pancreatitis.

Clinical and paraclinical:There are 4 main features
- High blood glucose (≥ 33.3 mmol/l) usually from 55.5 - 111.1 mmol/l
- No or very slight ketones in urine
- Plasma or serum osmotic pressure above 340 mosM
- Signs of severe dehydration.
Clinical differentiation between two types of coma.

Factors

Ketoacidosis

Increased osmotic pressure

Year old

Any age

Usually over 60 years old

Development

A few hours or a few days

A few days or weeks

Mortality rate (%)

> 5

50

Blood glucose

High

Very high

Osmotic pressure

High

Very high

Blood sodium

Normal or low

Normal or high

Bicarbonate

< 15

Normal or slightly low

Blood ketones

++++

Negative or slight +

Under treatment

Insulin

Diet ± DM lowering pills.

Paraclinical tests: Required for diagnosis and monitoring:
- Blood glucose
- Blood electrolytes, especially blood sodium
- Blood potassium.
- Blood urea and creatinine
- Bicarbonate, may increase slightly due to lactic acid accumulation (due to low blood pressure and reduced peripheral circulation).
The following formula can be used to calculate blood osmotic pressure:
Blood osmotic pressure = 2 (Na + K) + Urea + Glucose
(The unit for calculating the indexes is mmol/l).
Diagnosis is confirmed when ALTT > 340 mosM.
Principles of monitoring and treatment.
- Monitoring: As with ketoacidosis coma.
- Treatment: Patients must be treated in intensive care centers. Appropriate use of insulin, intravenous fluids and potassium is a condition to bring the patient out of the coma.
+ Replenish water and electrolytes: The most important factor, the chosen fluids are isotonic solutions. It is important to remember that when blood glucose levels drop, a secondary imbalance between intracellular and extracellular pressure occurs.
+ Insulin: Using insulin in small doses should be prescribed early. Patients with hyperosmolar coma are often sensitive to insulin, so they are susceptible to hypoglycemia, especially when infused intravenously. The initial dose may be similar to that of ketoacidosis coma; then continue to monitor to increase the dose until the glucose level reaches about 14-17 mmol/l, the insulin dose must be reduced by 1-2 units/hour and gradually switched to subcutaneous injection.
+ Anticoagulation: Unlike patients with ketoacidosis coma, patients with hyperosmolar coma have a much higher risk of embolism, so anticoagulation should be considered for these patients.
b) Chronic complications.
Often divided into large vessel and small vessel disease or according to the organ affected; for example
- Vascular diseases: Coronary atherosclerosis, Cerebral atherosclerosis, Peripheral vascular disease, Retinopathy, Glomerular disease.
- Neurological diseases: Sensory-motor neuropathy, autonomic neuropathy.
- Combined neurological and vascular diseases: Potholes, leg ulcers.
V. DISEASE PREVENTION
The content of diabetes prevention includes: prevention to avoid getting sick; when there is a risk of getting sick, prevention to prevent the disease from progressing and eliminating modifiable risk factors; when already sick, prevention to prevent the disease from progressing quickly and minimizing complications of the disease to improve the quality of life for the patient. The meaning of disease prevention in diabetes is no less important than treatment because it is also a part of treatment.
1. Level 1 disease prevention:Screening to identify at-risk populations; active intervention to reduce the incidence of diabetes in the community.
2. Level 2 prevention:for people with diabetes, to slow down the occurrence of complications, reduce the severity of complications, and improve the quality of life for people with the disease.
 
APPENDIX 1
DIAGNOSTIC CRITERIA FOR OVERWEIGHT AND OBESITY BASED ON BMI AND WAIST CIRCUMFERENCE FOR ADULTS IN THE ASIAN REGION (ACCORDING TO IDF, 2005)
(Issued with Decision No. 3280/QD-BYT dated September 9, 2011 of the Minister of Health)

Classify

BMI (kg/m²)

Combined risk factors

Waist measurement
<90cm (for men) ≥ 90cm
<80cm (for women) ≥ 80cm

Chicken

< 18.5

Low (but is a risk factor for other diseases)

Normal

Normal

18.5 - 22.9

Normal

Increase

Fat
+ At risk
+ Grade 1 obesity
+ Grade 2 obesity

≥ 23
23- 24.9
25- 29.9
≥ 30

 
Increase
Average increase
Heavy

 
Average increase
Heavy
Very heavy

 
APPENDIX 2
MEDICATIONS FOR THE TREATMENT OF TYPE 2 DIABETES
(Issued with Decision No. 3280/QD-BYT dated September 9, 2011 of the Minister of Health)
1. Oral hypoglycemic drugs
a) Metformin (Dimethylbiguanide): is a drug widely used in all countries. 30 years ago it was the main treatment for type 2 diabetes. Glucophage tablets 500 mg, 850 mg, 1000 mg
- Starting dose of 500 or 850 mg tablets: 500 or 850 mg (tablets/day)
- Maximum dose: 2500 mg per day
Metformin acts primarily by inhibiting hepatic glucose production but also increases peripheral insulin sensitivity. It lowers glucose by 2-4 mmol/l and reduces HbA1c by 2%. Because it does not stimulate pancreatic insulin secretion, it does not cause hypoglycemia when used alone.
Metformin is also a recommended drug for treating overweight and obese diabetics to maintain or reduce weight. The drug also has beneficial effects on reducing blood lipids.
Metformin can cause gastrointestinal side effects, so it should be taken with meals and started at a low dose (500 mg/day). The clinically effective dose range is 1500 mg to 2000 mg/day, and the maximum dose is 2500 mg/day.
Contraindications of metformin: severe heart failure, liver disease (including alcoholism), kidney disease (blood creatinine > 160 μmol/l), people with a history of lactic acidosis, because it increases the risk of lactic acidosis. Metformin is also contraindicated in cases of acute tissue hypoxia such as people with myocardial infarction, septic shock...
b) Sulphonylurea
Sulfonylurea stimulates the pancreas to secrete insulin. The average glucose-lowering effect is 50-60 mg/dl, reducing HbA1c by up to 2%. Sulfonylurea should be used with caution in the elderly, people with kidney disease (blood creatinine > 200 μmol/L) or liver dysfunction, in which case the dose should be reduced. Sulfonylurea should not be used to treat hyperglycemia in patients with type 1 diabetes, ketoacidosis, pregnant patients, and some other special conditions such as infection, surgery, etc.
Types of sulphonylure:
- Generation 1: Drugs in this group include tolbutamide, chlorpropamide, diabetol,... usually in 500 mg tablets. Drugs in this group are rarely used today due to their high toxicity to the kidneys (because the drug has a large molecular weight).
- Generation 2: Drugs in this group include glibenclamide, gliclazide, glipizide, glyburide...
Drugs of this generation have good blood glucose lowering effects and are less toxic than drugs of the first generation. The gliclazide group has specific effects on the K channel._ATPRestores early peak insulin secretion similar to physiological insulin secretion, so it causes less hypoglycemia than other sulfonylureas.
Glimepiride group: Good blood glucose lowering effect, in addition to stimulating pancreatic beta cells to secrete insulin similar to physiological insulin secretion (specific effect on K channel_ATPrestores the early peak of insulin secretion) also has the effect of increasing the sensitivity of peripheral tissues to insulin. The drug has few side effects and does not cause weight gain in overweight diabetic patients. It is only taken once a day, so it is convenient for the user (Diamicron 30mg MR, a 2nd generation drug, is also taken once a day).
The usual doses for these groups of drugs are:
- Glipizide from 2.5 mg to 20.0 mg/day.
- Gliclazide from 40 – 320 mg/day
- Gliclazide MR from 30 – 120 mg/day.
- Glimepiride from 1.0 - 6.0 mg/day - individually up to 8.0 mg/day.
- Glibenclamide from 1.25 - 15.0 mg/day.
Sulfonylureas are widely used as monotherapy or in combination with biguanides, glitazones, alfaglucosidase inhibitors, DPP-4 inhibitors, and insulin.
c) Alpha-glucosidase inhibition
Drugs that inhibit the enzyme alpha-glucosidase - the enzyme that breaks down carbohydrates into simple sugars (monosaccharides). This effect slows the absorption of monosaccharides, thereby lowering blood glucose levels after meals. Drugs in this group include:
- Generation 1 (acarbose group): This type often causes unwanted side effects such as bloating, diarrhea, etc.
The dose may be increased from 25mg to 50mg or 100mg/meal.
- 2nd generation (voglibose group): drugs in this group mainly inhibit the breakdown of disaccharides, so they have fewer unwanted effects.
The dose can be increased from 01 to 02 tablets/meal.
- Note when using the drug:
+ The drug needs to be used in combination with another type of blood glucose lowering drug.
+ Take medicine while eating.
c) Meglitinide/Repaglinide - drugs that stimulate postprandial insulin secretion.
In theory, this group does not belong to the sulfonylurea group; but it has the ability to stimulate pancreatic beta cells to secrete insulin - thanks to the benzamido group.
Regarding usage, it can be used as a monotherapy or in combination with Metformin, with insulin. There are also data proving that combining Repaglinide with NPH before bedtime achieves good results in treating hypoglycemia in people with type 2 diabetes.
Dosage: There are currently two drugs in this group.
- Repaglinide dose from 0.5 to 4 mg/meal. Maximum dose 16 mg/day.
- Netaglinide dose from 60 to 180 mg/meal. Maximum dose 540.0 mg/day.
d) Thiazolidinedione (glitazone)
The drug increases the sensitivity of muscle and adipose tissue to insulin by activating PPARg (peroxisome proliferator-activated receptor g) thus increasing glucose uptake from the blood. The drug increases insulin sensitivity in skeletal muscle, while inhibiting glucose production from the liver.
The main medication available is Pioglitazone. It can be used alone or in combination with other oral medications or insulin. Side effects include weight gain, fluid retention, and liver dysfunction. Liver function tests should be performed routinely every 2 months while taking the medication.
Dosage: Pioglitazone dose from 15 to 45 mg/day.
This group of drugs is contraindicated in people with symptoms or signs of heart failure, liver or kidney damage. Many experts and many countries also recommend not combining glitazone drugs with insulin.
d) Gliptin
Gliptins are DPP-4 (Dipeptidylpeptidase-4) inhibitors that increase endogenous incretin levels, which stimulate insulin secretion due to increased postprandial glucose.
There are two generations of DPP-4 inhibitors to date:
- DPP-4 inhibitors were first tested in the late 1990s, but were not used clinically.
- The first generation has been fully developed and applied to treatment, including the drug Sitagliptin (2007);
- The second generation is Saxagliptin (2009). In addition, drugs such as Vidagliptin (2008) are popular in Europe.
Dosage:
- Sitagliptin dose 100 mg/day
- Vildagliptin dose 2x50 mg/day.
- Saxagliptin dose 2.5 - 5 mg/day.
2. Combination of blood glucose lowering pills.

Ingredient

Concentration (mg)

Metformin + Glibenclamide

250:1.25; 500:2.5; 500:5.0

Metformin + Glipizide

250:2.5; 500:2.5; 500:5.0

Metformin + Pioglitazone

500:1.5; 850:1.5

Metformin + Vildagliptine

850:50; 1000:50

Metformin + Sitagliptin

500:50; 1000:50

Metformin + Repaglinide

500:1.0; 500:2.0

Pioglitazone + glimepiride

45:4

* Note: People often rely on the effects of the drug to divide the dosage and type of drug, so as to achieve maximum effect. Do not combine two types of drugs from the same drug group.
3. Insulin
a) Insulin use facilities
People with type 1 diabetes depend on exogenous insulin to survive. In contrast, people with type 2 diabetes do not depend on exogenous insulin to survive. However, after a period of illness, many people with type 2 diabetes have reduced or even lost the ability to produce insulin, requiring exogenous insulin supplementation to adequately control blood glucose.
Using insulin to achieve optimal glucose control requires understanding the duration of action of different types of insulin.
b) Types of human insulin according to duration of action

Insulin preparations

Start working

Peak effect

Time for the drug to be effective

Rapid-acting insulin:
- Insulin lispro
- Insulin aspart
- Insulin gluisin

 
5 - 15 minutes
5 - 15 minutes
5 - 15 minutes

 
30 - 90 minutes
30 - 90 minutes
30 - 90 minutes

 
3 - 5 hours
3 - 5 hours
3 - 5 hours

Short-acting insulin:
- Regular
- Actrapid®

 
30 - 60 minutes
30 minutes

 
2 - 3 hours
1 - 3 hours

 
5 - 8 hours
8 hours

Intermediate-acting insulin:
- Publisher
- Lente
- Insulatard® HM
- Insulatard® FlsxPen

 
2 - 4 hours
3 - 4 hours
1 - 1.5 hours
1 - 1.5 hours

 
4 - 10 hours
4 - 12 hours
4 - 12 hours
4 - 12 hours

 
10 - 16 hours
12 - 18 hours
24 hours
24 hours

Long-acting insulin:
Ultralente
- Glargine
- Determiner

 
6 - 10 hours
2 - 4 hours
2 - 4 hours

 
10 - 16 hours
No peak
6 - 14 hours

 
18 - 24 hours
20 - 24 hours
16 - 20 hours

Mixed insulin
- 70/30 human mix
- 70/30 aspart analog mix.
- Mixtard® HM (70/30)
- Mixtard® 30 FlexPen
- NovoMix®30 FlexPen

 
30 - 60 minutes
5 - 15 minutes
30 minutes
30 minutes
10 - 20 minutes

 
In 2 phases
In 2 phases
2 - 8 hours
2 - 8 hours
1 - 4 hours

 
10 - 16 hours
10 - 16 hours
24 hours
24 hours
24 hours

c) Injection procedure
Insulin should be injected into the subcutaneous tissue. Patients can self-inject by gently pulling back the skin fold and injecting at a 90-degree angle.^o. Thin people or children can use a short needle or can pinch the skin and inject at a 45 degree angle.^oto avoid injecting into a muscle, especially in the thigh area. Especially when using an insulin pen, the needle should be left in the skin for 5 seconds after the plunger has been fully depressed to ensure the full dose of insulin is delivered.
Insulin injections into the subcutaneous tissue of the abdomen are commonly used, but may also be given in the buttocks, thighs, or arms. Rotation of injection sites is necessary to prevent hypertrophy or atrophy of the subcutaneous fat tissue at the injection site.
d) Insulin storage
Insulin vials that are not in use should be kept in the refrigerator, but not in the freezer, and insulin should be kept away from sunlight. Excessive heat or cold and frequent shaking can damage insulin. Insulin in use can be kept at room temperature to minimize irritation at the injection site.
 
APPENDIX 3
RELATIONSHIP BETWEEN AVERAGE PLASMA GLUCOSE AND HBA1C
(Issued with Decision No. 3280/QD-BYT dated September 9, 2011 of the Minister of Health)

HbA1c %

Glucose HT (mg/dl)

Glucose HT (mmol/l)

6

126

7.0

7

154

8.6

8

183

10.2

9

212

11.8

10

240

13.4

11

269

14.9

12

298

16.5

 Editorial Board of Electronic Information Page - Department of Preventive Medicine, Ministry of Health

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