Emergencias

ABC DIABETES
OF
Fifth edition

Peter J Watkins

ABC OF DIABETES
Fifth Edition

ABC OF DIABETES
Fifth Edition

PETER J WATKINS
Honorary Consultant Physician, King’s Diabetes Centre, King’s College Hospital, London

© BMJ Publishing Group Ltd 1983, 1988, 1993, 1998, 2003

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, ortransmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. First edition 1983 Second edition 1988 Third edition 1993 Fourth edition 1998 Fifth edition 2003 by BMJ Publishing Group Ltd, BMA House, Tavistock Square, London WC1H 9JR www.bmjbooks.com British Library Cataloguing in Publication Data Acatalogue record for this book is available from the British Library ISBN 0-7279-16939

Typeset by Newgen Imaging Systems (P) Ltd, Chennai, India. Printed and bound in Spain by Graphy Cems, Navarra. The cover image shows molecular graphics of insulin hexamer with permission of JC Revy/Science Photo Library

Contents
Acknowledgments Introduction 1 2 3 4 5 6 7 8 9 What is diabetes? Clinicalpresentation: why is diabetes so often missed? Aims of treatment: a healthy lifestyle Treatment of Type 2 diabetes mellitus Insulin treatment Blood glucose monitoring: optimising diabetic control The unstable Type 1 diabetic patient Hypoglycaemia Diabetic ketoacidosis and management of diabetes during surgery vi vii 1 7 10 14 19 25 30 32 37 42 47 51 53 57 59 65 72 77 82 88 91 92 95

10 Diabeticcomplications: cause and prevention 11 Retinopathy 12 Peripheral neuropathies 13 Autonomic neuropathy 14 Mononeuropathies and acute painful neuropathies 15 The diabetic foot 16 Diabetic nephropathy 17 Cardiovascular disease, hypertension, lipids, and myocardial infarction 18 Pregnancy 19 Organisation of diabetic care: primary-secondary care interface 20 Practical problems Appendix 1 Further informationIndex

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Acknowledgments
Any ideas or inspiration which these pages may contain have inevitably been learnt or borrowed from others. I am indebted to the late Professor JM Malins and Dr MG FitzGerald, through whose enthusiasm I was first introduced to diabetes, and to the late Dr David Pyke through whose energy this interest has been fostered over many years. Close collaboration withcolleagues at King’s both past and present has made possible many of the joint ventures described here, and I am grateful to them all. Our registrars and research fellows and above all our patients have been a constant source of inspiration. I am particularly grateful to the many colleagues who have assisted me with the preparation of this book, especially Professor Stephanie Amiel (RD LawrenceProfessor of Diabetic Medicine), Dr Michael Edmonds and Dr Stephen Thomas (consultant physicians), Dr Tyrrell Evans (general practitioner), Dr Phin Kon (renal physician), Dr William Marshall (Reader in Clinical Biochemistry), Dr Joanna Raeburn (associate specialist), Ms Helen Reid (Diabetes Specialist Nurse), and Mrs Eileen Turner (Consultant Nurse Specialist). Dr Simon Page (consultant physician inNottingham) has helped me considerably by his many valuable comments in reading the manuscript. My wife Mrs Val Watkins has throughout provided me with invaluable support and encouragement.

Consultant physicians to the Diabetes Centre at King’s from 1938 (from left to right) Dr Wilfred Oakley (1905-1998); Dr David Pyke (1921-2001) and Dr Peter Watkins

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Introduction
Advances in clinicalscience over a single professional lifetime during the second half of the 20th century have led to improvements in understanding the causes and complications of diabetes, together with alleviation of suffering to an extraordinary degree, unimaginable even 25 years ago. Many of the clinical improvements have been initiated at innovative centres across the United Kingdom. In the 1960s and 1970s...