Gua Didctica No.

1
Diagnstico y tratamiento del paciente con diabetes tipo 2 en el contexto ambulatorio
y hospitalario
Tpicos clave:
CLASSIFICATION
Diabetes can be classified into the following general categories:
1. Type 1 diabetes (due to b-cell destruction, usually leading to absolute insulin deficiency)
2. Type 2 diabetes (due to a progressive loss of insulin secretion on the background of insulin
resistance)
3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of
pregnancy that is not clearly overt diabetes)
4. Specific types of diabetes due to other causes, e.g., monogenic diabetes sndromes (such as
neonatal diabetes and maturity-onset diabetes of the Young [MODY]), diseases of the exocrine
pancreas (such as cystic fibrosis), and drug- or chemical-induced diabetes (such as with
glucocorticoid use, in the treatment of HIV/AIDS or after organ transplantation) Criterios
diagnsticos para DM2
Criterios diagnsticos para DM
-A1c: >6,5%, Se dice hemoglobina glicada. Se altera su medicin en hemoglobinopatas y en
enfermdad renal cronica
-Glucemia en ayunas >126 mg/dl. Ayunas: 8 horas sin comida ni bebida (excepto agua).
-Glucemia 2 horas post test de carga oral de glucosa (75 gramos): >200 mg/dl.
-Paciente sintomtico, glucosa al azar >200 mg/dl.
Estos 4 anteriores requieren ser confirmados con otro test o con el mismo test.

Cada cunto pido la HbA1c?, si el paciente est en metas cada 6 meses. Si el paciente
est inestable y estoy titulando la terapia, se pide cada 3 meses.

Confirming the Diagnosis: Unless there is a clear clinical diagnosis (e.g., patient in a
hyperglycemic crisis or with classic symptoms of hyperglycemia and a random plasma glucose
$200 mg/dL [11.1 mmol/L]), a second test is required for confirmation.

Testing for Type 2 Diabetes and Prediabetes in Asymptomatic Adults

Metas glucmicas en paciente ambulatorio, hospitalizado y crtico

Paciente ambulatorio

Glycemic Targets
Perform the A1C test at least two times a year (cada 6 meses) in patients who are meeting
treatment goals (and who have stable glycemic control).
Perform the A1C test quarterly (cada 3 meses) in patients whose therapy has changed or who
are not meeting glycemic goals.

1. A reasonable goal for many nonpregnant adults is

A1C 7%
Prepandial o fasting glucose of 90130 mg/d,
bedtime glucose of 90150 mg/dLL

2. A stringent goals such as:

A1C 6.5% ,
Prepandial o fasting glucose of 90110 mg/d,
bedtime glucose of 90130 mg/dLL
is recomend in patients with any of the follow, if this can be achieved without significant
hypoglycemia or other adverse effects of treatment:

short duration of diabetes

type 2 diabetes treated with lifestyle or metformin only,
long life expectancy,
no significant cardiovascular disease

3. Less stringent goals such as

A1C 8%
Prepandial o fasting glucose of 90150 mg/d,
Bedtime glucose of 100180 mg/dLL
may be appropriate for patients with

history of severe hypoglycemia,

limited life expectancy,
advanced microvascular or macrovascular complications,
extensive comorbid conditions
long-standing diabetes in whom the general goal is difficult to attain despite diabetes selfmanagement education, appropriate glucose monitoring, and effective doses of multiple
glucose-lowering agents including insulin.

Severe hypoglycemia in patients with type 2 diabetes and cardiovascular disease may lead to
myocardial ischemia and may increase the risk of myocardial infarction, cardiac arrhythmias, or
sudden death. In general, the older the patient and the longer the duration of the disease, the
more established the atherosclerotic process and microvascular derangements, which usually
signify less benefit from intensive glycemic treatment.

Paciente hospitalizado

Paciente critico: glucose target of 140180mg/dL is recommended for most critically ill patients
Paciente hospitalizado no critico: glucose target of 90130mg/dL is recommended and <180
mg/dl postprandial

Hyperglycemia in hospitalized patients has been defined as blood glucose >140 mg/dL
Hypoglycemia in hospitalized patients has been defined as blood glucose <70 mg/dL (3.9
mmol/L) and severe hypoglycemia as <40 mg/dL

Esquemas de insulina en el paciente hospitalizado

Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a

threshold >180 mg/dL

A basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill
patients with poor oral intake or those who are taking nothing by mouth.
An insulin regimen with basal, nutritional, and correction components is the preferred treatment
for patients with good nutritional intake.

The treatment regimen should be reviewed and changed if necessary to prevent further
hypoglycemia when a blood glucose value is ,70 mg/dL

Insulin sensitivity may change dependig of the patient condition; most patients with type 2
diabetes (those who are overweight or who are receiving moderate doses of insulin [40 to 100 U

per day]) will require moderate correction doses (e.g., 2 U to correct blood glucose levels of 150
mg per deciliter, 4 U to correct levels of 200 mg per deciliter, and so on). Some patients with
type 2 diabetes and severe insulin resistance (those who are very obese, those receiving large
amounts of insulin [>100 U per day], or those taking corticosteroids) may require large corrective
doses (e.g., 4 U for blood glucose levels of 150 mg per deciliter, 8 U for levels of 200 mg per
deciliter, and so on)

Insulina: tipos disponibles, vidas medias, indicacin de insulinizacin.

Medicamentos orales y su rol en el tratamiento

HIPOGLUCEMIANTES ORALES

SULFONILUREAS
Acta sobre las clulas Beta pancreticas estimulando la secrecin de insulina

metformin, given the contraindications to its use (including renal impairment, heart failure, and
the need for radiographic contrast studies). Thiazolidinediones should be stopped if heart failure
or liver-function abnormalities are present. (Even after discontinuation, the antihyperglycemic
effects of this class of drugs may persist for several weeks.) In patients who are not eating
regularly, the insulin secretagogues (e.g., sulfonylureas) are particularly dangerous and glucosidase inhibitors are ineffective.