A Practical Guide to Diabetes Mellitus by Nihal Thomas, 8th edition, provides clinicians and trainees with the latest advances in the diagnosis and management of diabetes mellitus.
Beginning with an overview of physiology, epidemiology, pathogenesis and classification, the next chapters discuss related issues such as nutrition, exercise and counselling.
The following sections cover different aspects of the disease including emergency situations, therapeutic agents, and associated disorders including retinopathy, stroke, liver disease, and neuropathy.
The final chapters examine diabetes in specific demographic groups such as in pregnancy, obesity, in the elderly and in childhood and adolescence.
The eighth edition has been fully revised and includes new topics including new anti-diabetic drugs, recent clinical trials, and non-alcoholic fatty liver disease.
The book is highly illustrated with clinical photographs, tables and boxes, and each chapter concludes with MCQs (Multiple Choice Questions) with answers, for self-assessment.
Key points
- Eighth edition presenting latest advances in diagnosis and management of diabetes
- Fully revised, with many new topics added
- Features MCQs with answers for self-assessment
- Previous edition (9789351528531) published in 2015
About the Author
Nihal Thomas MBBS MD MNAMS DNB
Professor and Head, Department of Endocrinology, Associate Director
Nitin Kapoor MBBS MD DM ABBM Post-Doctoral Fellowship
Associate Professor, Department of Endocrinology, Diabetes and Metabolism
Jachin Velavan MBBS DNB MRCGP
Coordinator, Department of Distance Medical Education
All at Christian Medical College, Vellore, Tamil Nadu, India
Senthil Vasan K MBBS PhD
Post-Doctoral Researcher, University of Oxford, UK
Contents
1. Physiology 1
Solomon Sathish Kumar
• Pancreas 1
• Diabetes Mellitus 11
2. Introduction and Overview of Glycemic Disorders 16
Nihal Thomas, Senthil Vasan K
Part A: Epidemiology and Pathogenesis
• Epidemiology and Evolution 16
• Pathogenesis 19
Part B: Classification and Approach
• Classification 26
• History Taking in Diabetes 26
• Diagnosis of Diabetes Mellitus 29
• Concept of Prediabetes 29
• Concept of “The Metabolic Syndrome” 30
• Screening for Diabetes 34
• Summary of Recommendations for Adults with Diabetes Mellitus 34
• Glycosylated Hemoglobin 35
3. Practical Medical Nutritional Therapy 39
Mini Joseph, Leepica Kapoor, G Sai Mala
• Goals of Nutrition Therapy 39
• Maintenance of Body Weight 39
• Macronutrients 40
• Carbohydrates 41
• Protein 43
• Fat 44
• Micronutrients 47
• Nonnutritive Sweeteners 47
• Alcohol and Diabetes 47
• Fenugreek 48
• Food Exchanges 48
• Meal Planning 48
• Carbohydrate Counting 56
• Insight from the Nutritional Studies in Vellore 59
4. Exercise 63
Jubbin Jagan Jacob, Samuel Vinod Kumar
• Physiological Changes Occurring during Exercise 63
• Clinical Implications of the Effects of Exercise in Diabetes 64
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• Benefits of Exercise in Patients with Diabetes 64
• Potential Adverse Effect of Exercise in Patients with Diabetes 65
• Exercise Prescription 66
• Types of Physical Activity 72
• Practical Considerations 76
5. Counseling 80
Ruchita Mehra Srivastava
• Steps in Counseling 80
• Case Studies 91
6. Oral Antidiabetic Agents 98
Nitin Kapoor, Senthil Vasan K, Nihal Thomas
• Role of Oral Antidiabetic Agent Therapy in Type 2 Diabetes Mellitus 98
• Biguanides 98
• Sulfonylureas 101
• Meglitinide 104
• a-Glucosidase Inhibitors 105
• Thiazolidinediones 106
• Incretin Effect 108
• Hydroxychloroquine in Diabetes 112
• Sodium-Glucose Cotransporter 2 Inhibitors 112
• Bromocriptine 114
• Guidelines for Initiating Oral Antidiabetic Agents 115
7. Parenteral Therapeutic Agents 124
Sahana Shetty, Senthil Vasan K, Nitin Kapoor, Nihal Thomas
• Insulin Therapy 124
• History 125
• Classification of Insulin 125
• Glucagon-like Peptide 1 Analogs 136
• Amylin Analog 140
• Case Studies 141
8. Insulin Therapy—Practical Aspects 146
Ruth Ruby Murray, Vijayalakshmi A
• Insulin Syringes 147
• Factors that Affect Rate of Absorption of Insulin 152
• Complications of Insulin Therapy 153
• Barriers to Insulin Therapy 157
• Sick-day Management 158
• Alternative Methods of Insulin Delivery 159
• Determining Effectiveness of Self-injection 161
• Dose Adjustment for Normal Eating 168
• Insulin Port (I-Port) 169
• Flash Glucose Monitoring System 169
9. Gadgets and Glucose Monitoring 177
Felix Jebasingh K, Ruth Ruby Murray
• Self-monitoring of Blood Glucose 177
• Continuous Glucose Monitoring System 183
• Flash Glucose Monitoring System 184
• Other Gadgets Used in Diabetes 188
• Newer Upcoming Products for Diabetes-related Problems 189
10. Peripheral Neuropathy 192
Mahesh DM, Thomas V Paul, Nihal Thomas
• Risk Factors 193
• Classification 193
• Pathogenesis 194
• Clinical Presentation 195
• Management 203
11. Feet, Foot Care, and Neuroarthropathy 213
Riddhi Dasgupta, Bharathi S, Sunitha R, Edwin Stephen,
Jubbin Jagan Jacob, Nihal Thomas, Hari Krishna Nair
Part A: Foot Care and Neuroarthropathy
Riddhi Dasgupta, Bharathi S, Sunitha R, Edwin Stephen, Jubbin Jagan Jacob, Nihal Thomas
• Ulceration 213
• Neuroarthropathy 223
• Peripheral Artery Occlusive Disease 231
Part B: Wound Care in Patients with Diabetes
Hari Krishna Nair
• Wound Assessment 238
• Wound Cleansing 239
• Debridement 239
12. Therapeutic Footwear 245
Riddhi Dasgupta, Felix Jebasingh K, Judy Ann John,
Bobeena Rachel Chandy, Rajan P, Premkumar R
• Foot Injury Mechanism due to Sensory Neuropathy 245
• Foot Injury Mechanism due to Motor and Sensory Neuropathy 246
• Foot Examination for Selecting Appropriate Foot Orthotics 247
• Selection of Footwear 250
13. Hypertension 269
Sudeep K, Jubbin Jagan Jacob
• Obesity 271
• Renovascular Hypertension 271
• Primary Hyperaldosteronism 272
• Screening and Initial Evaluation 274
• Target Blood Pressure 274
• JNC 8 Report 275
• Nonpharmacologic Therapy of Hypertension 275
• Pharmacotherapy of Hypertension 276
• Resistant Hypertension 282
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xxiv A Practical Guide to Diabetes Mellitus
14. Nephropathy 286
Santosh Varghese, Suceena Alexander
• Risk Factors 287
• Classification 287
• Survival in Patients with Diabetic Nephropathy 289
• Pathogenesis of Nephropathy 289
• Pathology 290
• Differentiating from Other Causes of Kidney Diseases 291
• Management 292
• Renin-Angiotensin-Aldosterone System Blockade 293
• What should be Done When the GFR has Begun to Decline? 295
• Avoidance of Further Injury 297
• Supportive Treatment for the Chronic Kidney Disease Patient 298
• Investigations 300
• Renal Replacement Therapy 300
• Normoalbuminuric Chronic Kidney Disease in Diabetes 301
• Newer/Experimental Therapy for Diabetic 302
15. Macrovascular Complications in Diabetes 305
Shubhrangshu Dey, Viji Samuel, Sanjith Aaron
Part A: Cardiovascular Complications and Dyslipidemia
Subhrangshu Dey, Viji Samuel
• Epidemiology 305
• Diabetes Mellitus and Cardiovascular Disease 305
• Diabetic Dyslipidemia 311
Part B: Stroke and Diabetes
Sanjith Aaron
• Risk for Stroke in a Patient with Diabetes 317
• Primary and Secondary Stroke Prevention
Strategies in Diabetics 317
• Diabetes in the Setting of Acute Ischemic Stroke 318
• Other Special Considerations in a Diabetic Patient with a Stroke 319
16. Ocular Disease and Retinopathy 321
Smitha Jasper, Saban Horo, Padma Paul
• Vision and Refraction Changes in Diabetes 321
• Diabetes and Changes in the Orbit and Extraocular Muscles 321
• Ocular Surface Changes in Diabetes 322
• Diabetes and the Lens 323
• Diabetes and Glaucoma 323
• Diabetes and the Pupil 324
• Diabetes and the Optic Nerve 324
• Acute and Chronic Causes of Vision Loss in Diabetes 325
• Diabetic Retinopathy 325
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Contents xxv
• Ophthalmoscopy 331
• Recording of Fundus Findings 335
17. Diabetes and Nonalcoholic Fatty Liver Disease 338
Nitin Kapoor, Nihal Thomas
• Problem Statement 338
• Natural History of the Disease and Pathophysiology 338
• Evaluation of Nonalcoholic Fatty Liver Disease 339
• Management of Nonalcoholic Fatty Liver Disease and Diabetes 341
18. Autonomic Neuropathy 347
Kanakamani Jeyaraman
• Epidemiology of Diabetic Autonomic Neuropathy 347
• Pathogenesis 348
• Clinical Manifestations of Diabetic Autonomic Neuropathy 349
• Current Guidelines for the Diagnosis of Diabetic
Autonomic Neuropathy 364
• Management Implications of Diabetic Autonomic Neuropathy 365
19. Infections in Diabetes 368
George M Varghese, Ravikar Ralph, Abraham OC
• Specific Infections 370
20. Cutaneous Manifestations of Diabetes Mellitus 387
Anju George, Renu George
• Microangiopathies 387
• Neurovasculopathies 391
• Obesity- and Hyperlipidemia-related Skin Disorders 392
• Infections 393
• Sclerodermatous Changes 399
• Associations with Diabetes Mellitus 401
• Cutaneous Complications of Insulin and Oral Antidiabetic Agents 406
21. Hyperglycemic Emergencies 409
Jubbin Jagan Jacob
• Precipitating Factors 410
• Pathophysiology of Diabetic Ketoacidosis and
Hyperosmolar Hyperglycemic State 410
• Clinical Recognition, Establishing a Diagnosis, and
Assessment of Comorbidities 412
• Diagnostic Evaluation and Laboratory Studies 413
• Clinical Management of Diabetic Ketoacidosis and
Recognition of Complications 414
• Complications 420
• Special Situations 421
• Use of Inpatient Standard Management Protocols in
Diabetic Ketoacidosis 423
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• Clinical Management of Hyperosmolar Hyperglycemic State 423
• Prognosis 424
22. Hypoglycemia 427
Nitin Kapoor, Nihal Thomas, Jubbin Jagan Jacob
• Clinical Classification of Hypoglycemia 427
• Pathophysiology of Counterregulation 428
• Causes 428
• Clinical Recognition of Hypoglycemia 429
• Clinical Management of Hypoglycemia 431
• Long-term Management 433
• Hypoglycemia-associated Autonomic Failure 433
• Recurrent Hypoglycemia 433
• Consequences 433
23. Pregnancy and Diabetes 438
Mahesh DM, Philip Finny, Kanakamani Jeyaraman
• Terminology 439
• Gestational Diabetes Mellitus 441
• Pregestational Diabetes 448
• Management 449
• Future Risks in Mother 454
24. Diabetes in Childhood and Adolescence 458
Asha HS, Riddhi Dasgupta, Aaron Chapla, Veena V Nair
• Epidemiology 458
• Diagnosis 458
• Classification 459
• Clinical Features 462
• Approach to Diagnosis 464
• Management 465
• Chronic Complications 471
• Acute Complications 473
• Sick-day Management 474
• Type 2 Diabetes in Children 476
25. Diabetes in the Elderly 480
Rahul Baxi, Nihal Thomas
• Diabetes in the Older Adult: How is it Different? 480
• Management of Diabetes in the Elderly 481
26. Secondary Diabetes and Other Specific Types 488
Dukhabandhu Naik, Nitin Kapoor, Nihal Thomas
• Classification of Secondary Diabetes 488
• Chronic Complications in Secondary Diabetes 499
• Other Specific Types of Diabetes 501
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Contents xxvii
27. Perioperative Care 507
Georgene Singh
• Metabolism at Rest 507
• Metabolic Challenge of Surgery 508
• Preoperative Management of Diabetic Patients 508
• Level of Glycemic Control 508
• Classification of the Type of Surgery 513
• Management of Diabetes 513
• Choice of Anesthesia 514
• Premedication 515
• Intraoperative Anesthetic Management of Diabetic Patients 515
• Point-of-Care Glucose Measurements 517
• Major Surgery Regimen 517
• Management of Diabetic Patients under Different Modes of Anesthesia 518
• Problems to be Anticipated in a Diabetic Patient under Anesthesia 519
• Emergency Surgery in the Diabetic Patient 521
• Special Clinical Scenarios 521
• Postoperative Management of Diabetic Patients 521
28. Obesity with Diabetes 525
Nitin Kapoor, Inian Samarasam, Nihal Thomas
• Definition of Obesity 525
• Epidemiology of Obesity and its Impact on Diabetes 525
• Etiopathogenesis of Obesity 526
• Evaluation of Obesity 527
• Management 530
29. Laboratory and Analytical Methods 540
Geethanjali Arulappan, Charles Stephen
• Laboratory Errors 540
• Preanalytical, Analytical, and Postanalytical Errors 541
• Role of Laboratory in Diabetes Management 544
• Available Assays 545
• Other Tests of Relevance 550
30. Recent Advances 555
Sahana Shetty, Nihal Thomas
• Newer Drugs for the Management of Diabetes Mellitus 555
• Newer Incretin-based Therapies 557
• Once-weekly Dipeptidyl Peptidase-4 Inhibitors 557
• Newer Insulin Secretagogues 558
• Insulin Receptor Activators 560
• New Hepatic Targets for Glycemic Control in Diabetes 561
• Novel Insulin Formulations 563
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xxviii A Practical Guide to Diabetes Mellitus
• Bionic Pancreas 564
• Immunotherapy for Type 1 Diabetes 565
• Pancreatic Transplant and Pancreatic Islet Cell Transplantation 566
• Stem Cell Therapy 567
• Gene Therapy 569
31. In-hospital Management of Diabetes 573
Rahul Baxi, Nihal Thomas
• Effects of Hyperglycemia in Hospitalized Patients and Benefits
of Glycemic Control 573
• Which Patient should We Admit? 573
• Aims and Targets 575
• Diabetes Inpatient Team 575
• Paradox: Barriers to Glycemic Control in Hospital 576
• Common Errors in Management 576
• Glucose Control 578
• Diabetes Management in the Critically Ill Patients 581
32. Integrating Systems 585
Flory Christina, Nihal Thomas, Abraham Joseph, Senthil Vasan K,
Vinod Shah, Hasna Rajesh
Part A: Team Approach to the Management of Diabetes
Flory Christina, Nihal Thomas, Abraham Joseph, Senthil Vasan K
• Disease Prevention 585
• Prevention and its Importance 586
• Integrated Diabetes Clinics 587
• Functionaries of an Integrated Diabetes Clinic and their Role 588
• Improving Foot Care for People with Diabetes Mellitus:
An Integrated Care Approach 592
• Diabetes Support Groups 593
Part B: Telehealth—Bridging Distances in Diabetes
Vinod Shah, Hasna Rajesh, Nihal Thomas
• Telehealth Classroom Setup 598
• Desktop Conference: Web-based Learning Method 600
• Requirements for Quality Transmission 601
• Administrative Challenges and Issues 602
Answers to All MCQs 605
Appendices 609
1. Dietary Recommendations 611
2. A Quick Guide for Choosing Footwear, MCR Add-ons and Braces 617
3. Evidence in Medicine 618
4. Diabetes Case Record 619
5. Patient Handouts and Educational Material 623
Final Assessment 629
Index 671
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