National Guideline On Diabetes Mellitus, First Edition 2023

National Guideline
on Diabetes Mellitus
First Edition
Non Communicable Disease Control Programme

Directorate General of Health Services
Ministry of Health & Family Welfare
Published by
Non-Communicable Disease Control Programme (NCDC)
Directorate General of Health Services (DGHS),
Mohakhali, Dhaka 1212, Bangladesh.
Phone:+88-02-9899207,
E-mail:[email protected]
www.ncdc.gov.bd
First Edi�on
July - 2023
Printed By
Bangladesh Machine Tools Factory
Non Communicable Disease Control Programme

National Guideline on Diabetes Mellitus
Chief Advisor:
Professor Dr. Abul Bashar Mohammed Khurshid Alam
Director General,
Directorate General of Health Services, Mohakhali, Dhaka.
Advisors:
Dr. Rasheda Sultana
Addi�onal Director General, (Admin),
Directorate General of Health Services, Mohakhali, Dhaka
Prof. Dr. Ahmedul Kabir
Addi�onal Director General, (Planning & Development)
Directorate General of Health Services, Mohakhali, Dhaka
Editor in Chief :
Professor Dr. Mohammad Robed Amin
Line Director,
Non Communicable Disease Control (NCDC) Programme, DGHS, Mohakhali, Dhaka.
Managing Editor
Dr. Rafique-Us-Saleheen,
Programme Manager -01,
Deputy Managing Editor:

Dr. Rahat Iqbal Chowdhury
Deputy Programme Manager-1
Core Editors:
Prof. Dr. Md. Feroz Amin
Prof. Dr. Indrajit Prasad
Dr. Bishwajit Bhowmik
Dr. Faria Afsana
Dr. Shahjada Selim
Dr. Nazmul Kabir Qureshi
Dr. Tareen Ahmed
Editorial Assistance:
Dr. Md. Shahidul Islam
Dr.Ashim Chakraborty
Dr. Md. Akhtaruzzaman
Dr. Nusaer Chowdhury
Technical Support :
Japan Interna�onal Coopera�on Agency Diabe�c Associa�on of Bangladesh

Father Of The Nation Bangabandhu Sheikh Mujibur Rahman
1st IDF Global Ambassador for Diabetes
Honourable Prime Minister of Bangladesh Sheikh Hasina has been nominated as 1st IDF Global Ambassador
for Diabetes in recognition of her role to ensure affordable access to health care for people with diabetes and
other non-communicable diseases during the opening ceremony of the International Diabetes Federation (IDF)
world diabetes congress held in Lisbon, Portugal on 5 December 2022. The role will lasts for next two years.
Advisory Group Members
Mr. Zahid Maleque MP National Prof. AK Azad Khan

National Prof. Brig. (Rtd.) Abdul Malik Prof. Akhtar Hussain
Dr. Md. Anwar Hossain Howlader Prof. Dr. ABM Khurshid Alam
Prof. Dr. A.H.M. Enayet Hussain Prof. Dr. AKM Amirul Morshed
Prof.Dr. Harun Ur Rashid Prof. Hajera Mahtab
Prof. Dr. Ahmedul Kabir Dr. Rasheda Sultana
Task Force Members
Prof. Md. Robed Amin Prof. Md.Faruque Pathan

Prof. Md. Farid Uddin Prof. SM Ashrafuzzaman
Prof. MA Hasanat Prof. M A Jalil Ansary
Prof. Md.Hafizur Rahman Prof. Ruhul Amin
Prof. Md.Feroz Amin Prof. Indrajit Prasad
Prof. Mir Mosarraf Hossain Dr. Tareen Ahmed
Dr. Faria Afsana Dr. Bishwajit Bhowmik
Dr.Shahjada Selim Dr.FazleAlahi Khan

Dr. Sarwar Uddin Milon Dr. Rafique-us-Saleheen
Dr. Rahat Iqbal Chowdhury
Working Group Members
Chapter-1 Dr. Bishwajit Bhowmik Chapter-2 Dr. Nazmul Kabir Qureshi

Epidemiology, Dr.Rahat Iqbal Chowdhury Screening and Dr. Dahlia Sultana
Classification, Dr. Akhtar Ahmed Diagnosis of Dr.Tahniya Haque
Pathophysiology and Dr. Kazi Ali Hassan Diabetes Mellitus Dr. Md. Anwar Hossain
Clinical Presentation of Prof. Mir Mosarraf Hossain Dr.FazleAlahi Khan
Diabetes Mellitus Dr. Rafique-us-Saleheen Prof. MA Hasanat
Prof. Md.Faruque Pathan
Chapter-3 Dr. Faria Afsana Chapter-4 Dr. Tareen Ahmed

Treatment of Dr. M Saifuddin Acute Complications Dr. Tasnima Siddiquee
Diabetes Mellitus Dr. Md.Azizul Haque of Diabetes Mellitus Dr. Mohammad Nurul Amin
Prof. Zafar Ahmed Latif Prof.Laique Ahmed Khan
Prof. SM Ashrafuzzaman Prof.Tofail Ahmed
Chapter-5 Prof. Md.Feroz Amin Chapter-6 Prof. Indrajit Prasad

Chronic Complications Prof. Nazrul Islam Siddiqui Special Situations Dr.Tanjina Hossain
of Dr. Ahmed Salam Mir in Diabetes Mellitus Dr. MarufaMustari
Diabetes: Prevention Dr. Samir Kumar Talukder Dr. MA Samad
and Management Prof. Md. Farid Uddin Dr.AminulIsram
Prof. Ruhul Amin
Chapter-7 Dr.Shahjada Selim

Prevention of Dr. Mosfiqur Hossain
Diabetes Mellitus Dr. ABM Kamrul Hasan
Dr. Halim Khan
Dr. HM Nazmul Ahsan
Prof. Md Hafizur Rahman
Honorable Prime Minister
Government of the People’s Republic of Bangladesh &
1st IDF Global Ambassadorfor Diabetes
Message
Diabetes is a global issue. Like many other countries, Bangladesh is also suffering from an epidemic of diabetes.
It makes a significant contribution to morbidity and mortality in Bangladesh. International Diabetes Federation
(IDF) reported the total number of diabetic people is nearly 13.1 million in Bangladesh which is the 8th position
in the world. By 2045, it is projected to move to the 7th position, with 22.3 million people with diabetes. In addi-
tion, the total number of diabetes-related death was nearly seventy-six thousand in 2021.
Diabetes is a chronic illness that requires continuing medical care and patient self-management education for
optimal management outcomes and reducing the risk of complications. The impact of diabetes on families,
communities, and nations is not sustainable and it is little wonder that the 2006 UN Resolution on Diabetes
called on world governments to ‘develop national policies for the prevention, treatment, and care of diabetes in
line with the sustainable development of their healthcare systems’.
Remarkable progress has been made in the health sector of Bangladesh in the last 14 years despite having
various limitations. The government has made healthcare services more affordable and reached almost every
doorstep making Bangladesh self-resilient in screening and treating non-communicable diseases (NCD) includ-
ing diabetes. The government has introduced around 290 NCD Corners at Upazila Health Complex throughout
the country. Besides screening, registration, diagnosis, and treatment facilities, they provide free medications
(including two oral antidiabetics, three antihypertensives, one lipid-lowering medication, and aspirin) to all
eligible registered patients. The government is also providing free insulin to all type 1 diabetic people and
insulin-dependent type 2 diabetic people. In addition, the availability of basic healthcare services with free
diabetes and hypertension screening have also been possible at the primary care level due to the establishment
of community clinics. The NCDC program of the DGHS recognizes that this chronic illness should require man-
agement and control, based on a national guideline. This guideline will ensure standardized medical care and
patient self-management education to prevent acute complications and reduce the risk of long-term complica-
tions from the disease.
I appreciate NCDC and all the experts who have worked hard to make this guideline a reality and express my
sincere gratitude and appreciation for their contribution. Thanks to the Centre for Global Health Research of the
Diabetic Association of Bangladesh and JICA for their technical assistance. After all, a guideline is only valuable
and useful when it is implemented in the field of day-to-day clinical practice. Therefore, I would like to recom-
mend to all clinicians to use this diabetes care guideline for the optimal management of diabetes in their
settings.
Joi Bangla, Joi Bangabandhu

May Bangladesh Live Forever
Sheikh Hasina, MP
Honorable Health Minister
Ministry of Health and Family Welfare
Government of the People’s Republic of Bangladesh
Message
Diabetes Mellitus is running on an epidemic scale almost all over the world, Bangladesh is no
exception. Day by day, the number of patients are increasing and they are more prone to be
affected by different types of comorbid conditions. Physicians are playing an important role to
ensure better care. But they face problems to individualize the treatment. I am happy to learn
that NCDC has developed the first national diabetes guideline with technical assistance from
JICA and the Diabetic Association of Bangladesh. I express my heartfelt thanks to all the mem-
bers of the expert committee for putting their effort to develop the guideline. This guideline will
help and guide a physician in making a decision towards treatment in addition to enriching their
knowledge of the current treatment approach.
From the Government side, we want to maintain a collaboration with all the stakeholders to take
such type of initiative in the future which is in line with the non-communicable disease control
program of the Government.
I sincerely hope this guideline will be helpful to physicians and will serve a useful purpose in
daily practice.
Zahid Maleque, MP
President
Diabe�c Associa�on of Bangladesh&
Chair, IDF South East Asia
Message
It gives me immense pleasure to know that NCDC, DGHS is publishing the country’s first national
diabetes guideline. I express my heartfelt thanks to all the members of the task force team and
expert committee for putting their effort to develop the guideline.
The world is suffering from an epidemic of diabetes and this epidemic is rising faster in developing
countries like Bangladesh; hence the number of increasing patients need to get access to quality
care for getting optimal control. It is well known that to ensure quality care competence building
of physicians is of utmost need.
I believe this guideline will help the physician to choose the right regimen for treating people with
diabetes. I also believe this initiative will expand the specialist physician base and will empower the
physicians to enhance the treatment of diabetes ensuring quality care.
I look forward to the success of this guideline.
National Prof. AK Azad Khan

Secretary
Health Service Division
Message
I am immensely delighted to know that NCDC, DGHS is publishing the country’s first national
diabetes guideline. I would like to take this moment to express my heartfelt gratitude to all
members who worked relentlessly to develop this guideline. Thanks to JICA and BADAS for their
technical assistance.
The number of Diabetic Patients is increasing worldwide and also in Bangladesh at an alarming
rate. As a result, an increased number of patients need to get access to quality care for achieving
optimal control, and capacity building of the physicians is a time-demanding need.
I believe these initiatives will expand the specialist physicians base and will empower the physi-
cians and will help to progress further towards fulfilling the vision of creating a Smart Bangla-
desh.
I look forward to the success of this guideline.
Dr. Md. Anwar Hossain Howlader

Director General
Message
Across the world diabetes is a common burden. We are facing the same challenges in Bangla-
desh. About 13.1 million people in Bangladesh have diabetes. This figure would be just doubled
by the year 2045. We are struggling to provide quality care to people with diabetes due to the
limited number of diabetes specialists. I believe this national diabetes guideline from NCDC will
guide a physician to select appropriate therapy to manage diabetes as well as boost the treat-
ment knowledge of physicians and ensure a better treatment in individualized care.
We are happy to see such type of initiative of NCDC and appreciate their effort to publish this
guideline.
We look forward to the success of this and believe it would be a widely used guideline among
physicians.
Prof. Dr. ABM Khurshid Alam

Chief Representa�ve
JICA Bangladesh Office
Message
It is my great pleasure that the National Diabetes Guidelineis launched by the Government of Bangla-
desh (GOB).JICA recognizes that Non-Communicable Diseases (NCDs), including diabetes, are a grow-
ing public health concern in Bangladesh, affecting a significant portion of the population and leading to
high morbidity and mortality. Nevertheless, thanks to initiatives by the GOB to improve people’s access
to NCDs services, remarkable progress has been made over the past few years in instituting measures
against NCDs, particularly diabetes and hypertension.
JICA has been providing support in the health sector through financial and technical cooperation with
the GOB. Currently, the prevention of NCDs is one of our prioritiesas seen inJICA’s implementation of
the “Project for Strengthening Health Care Systems for Organizing Communities (known as
SHASTO)”until 2022. The project worked closely with the Non Communicable Disease Control
Program(NCDC) and theDirectorate General of Health Services (DGHS) to develop and implement the
NCDC Program activities, including promoting the NCDs management model to prevent hypertension
and diabetes. We are happy to celebrate the lauchning of this guideline as a output of SHASTO project.
JICA is delighted to continue the collaboration with NCDC and DGHS for launching anew project on
strengthening healthcare systems for preventing NCDs this year.
This national diabetes guideline aims to provide evidence-based guidance for the prevention, diagno-
sis, and management of diabetes in Bangladesh, which is tailored to local needs, practices, and resource
availability. It covers various aspects of diabetes care including risk assessment, screening, glycemic
control, lifestyle intervention, the use of medications and insulin therapy, and the management of
diabetes-related complications, such as neuropathy, retinopathy, and nephropathy.
The guideline, which was developed through the efforts of experts on diabetes care in Bangladesh,fully
reflects the accumulated expertise in such care. We believe this will help healthcare professionals
responsible for those with diabetes ensure essential, high-quality healthcare services that improve the
health outcomes and quality of life of patients while reducing the burden the disease places on those
patients and on the healthcare system.
We remain committed to working with the Government of Bangladesh and our other partners to reduce
the impact of NCDs on the country
Ichiguchi Tomohide
Line Director
Non-communicable Disease Control Program
Preface
I express my heartiest thanks to all the members of the task force and the expert committee of
the National Diabetes Guideline for their brilliant contribution to publishing this guideline. Thanks
to BADAS and JICA for their technical support.
Diabetes is a chronic lifelong disease. If undetected or uncontrolled, it can lead to life-threatening

acute emergencies and long-term chronic complications leading to blindness, end-stage kidney
disease, neurological complications, and cardiovascular disease. Research has proved that all
these complications are largely preventable by early detection and good control of diabetes. I
believe this guideline will guide our physicians to choose the appropriate treatment regimen for
the management of their patients properly.
We look forward to your gracious support to these and make it a grand success.
Prof. Dr. Md. Robed Amin

Editor-in-Chief
Abbreviations
ACEI Angiotensin-Conver�ng Enzyme Inhibitors
AER Albumin Excre�on Rate
AGI Alpha-Glucosidase Inhibitors
ALA Alpha �ipoic �cid
ALT Alanine �mino �ransferase
ARB Angiotensin II �eceptor blockers
ASCVD Athero Sclero�c Cardio Vascular Disease
BG Blood Glucose
BMI Body Mass Index
BP Blood Pressure
BUN Blood Urea Nitrogen
CAD Coronary Artery Disease
CBC Complete Blood Count
CCr Crea�nine Clearance
CGM Con�nuous Glucose Monitoring
CKD Chronic Kidney Disease
CVD Cardio Vascular Disease
DHA Docosa Hexaenoic Acid
DIC Disseminated Intravascular Coagula�on
EPA Eicosa Pentaenoic Acid
DKA DM - Diabetes Mellitus
eGFR Es�mated Glomerular Filtra�on Rate
ESRD End-Stage Renal Disease
GAD Glutamic Acid Decarboxylase
GFR Glomerular Filtra�on Rate
GI Gastro Intes�nal
HbA1c Glycated Hemoglobin
hCG Human Chorionic Gonadotropin
HDL High-Density Lipoproteins
HHS Hyperosmolar Hyperglycemic State
HIV Human Immunodeficiency Virus
HLA Human Leukocyte An�gen
IDF-DAR Interna�onal Diabetes Federa�on - Diabetes and Ramadan
IHD Ischemic Heart Disease
ISPAD Interna�onal Society for Pediatric and Adolescent Diabetes
LAD Le� anterior Descending Artery
LDL Low-Density Lipoproteins
LGA Large for Gesta�onal Age
MDI Mul�ple Dose Injec�on
MEN-2 Mul�ple Endocrine Neoplasia Syndrome Type 2
MI Myocardial Infarc�on
MNT Medical Nutri�on Therapy
MTC Medullary Thyroid Cancer
NAFLD Non Alcoholic Fa�y Liver Disease
NCD Non Communicable Disease
NPH Neutral Protamine Hagedorn
NPO Nothing by Mouth
PCI Percutaneous Coronary Interven�on
PCOS Poly Cys�c Ovary Syndrome
PDE5 Phospho Diesterase 5
PPAR Peroxisome Proliferator-Ac�vated Receptors
RTI Respiratory Tract Infec�on
SC Sub Cutaneous
SMBG Self-Monitoring of Blood Glucose
SU Sulfonyl Ureas
TDD Total Daily Dose
TPN Total Parenteral Nutri�on
tTG Tissue Trans Glutaminase
UTI Urinary Tract Infec�on
WC Waist Circumference
Contents
Introduction i-ii
Chapter-1 1-7
Epidemiology, Classification, Pathophysiology and
Clinical Presentation of Diabetes Mellitus
Chapter-2 8-14
Screening and Diagnosis of Diabetes Mellitus
Chapter-3 15-31
Treatment of Diabetes Mellitus
Chapter-4 32-41
Acute Complications of Diabetes Mellitus
Chapter-5 42-53
Chronic Complications of Diabetes: Prevention and Management
Chapter-6 54-79
Special Situations in Diabetes Mellitus
Chapter-7 80-84
Prevention of Diabetes Mellitus
Introduction
Introduction
Diabetes is a major health issue that has reached a pandemic level. In Bangladesh, the
treatment of diabetes is mainly provided by general physicians and specialist physicians,
including endocrinologists and diabetologists, through government and private
healthcare facili�es. However, in some union-level government facili�es, medical
assistants detect high blood glucose and refer for treatment to physicians. Compliance
with diabetes treatment is low mainly due to insufficient knowledge about disease
control and preven�on of complica�ons, and the long-term cost of drugs in the case of
poor pa�ents. Lack of updated informa�on and current recommenda�ons on diabetes
management for physicians are also important barriers to providing proper care.
Although several interna�onal guidelines for diabetes management are now available,
a guideline specific to the Bangladeshi popula�on is required for the appropriate
management of diabetes by physicians and healthcare providers working at various
levels of the healthcare system in Bangladesh.
Objective
The objec�ve of this na�onal diabetes guideline is to provide clear and concise evidence
to all healthcare providers on the current concepts in the management of diabetes.
Since diabetes is managed by various levels of healthcare providers in Bangladesh,
a�empts are made to ensure that different stakeholders will benefit from this
guideline.
i
Methods
To develop the guideline, the Noncommunicable Disease Control (NCDC) Program of
the Directorate General of Health Services (DGHS) set up three groups – a working
group, a task force group, and an advisory group. Both working and task force groups
comprised leading experts from endocrinology, diabetology, internal medicine,
nephrology, primary care medicine, and public health in Bangladesh. The advisory
group consists of both renowned clinicians and government policymakers. Centre for
Global Health Research, the Diabe�c Associa�on of Bangladesh (BADAS), and the Japan
Interna�onal Coopera�on Agency (JICA) provided technical support. ‘Diabetes Care
BADAS Guideline 2019’, a joint ini�a�ve of NCDC and BADAS, was a baseline document
for guideline development. In addi�on, members of the working group reviewed recent
diabetes care and preven�on guidelines published by various interna�onally
authorita�ve scien�fic and professional bodies. Also, they examined the recent reports
on newer studies related to diabetes management to formulate a ‘zero dra�.’ A�er
comple�ng the zero dra� presenta�on, the working group members conducted a series
of consulta�ons. A dra� document comprising seven chapters with a summary was
developed. Each reference that was used to formulate this guideline was cri�cally
reviewed. The task force group, consis�ng of eighteen members, worked on this
document and finalized it a�er making necessary changes. A four-member independent
review commi�ee reviewed this document, which was then uploaded to the DGHS
website for public comments. Finally, the guideline was approved by the advisory group
members.
Duration
June 2022 to November 2022
ii
Chapter-1
Epidemiology, Classification,
Pathophysiology and
Clinical Presentation of
Diabetes Mellitus
- 1 -
CHAPTER - 1
Epidemiology, Classification, Pathophysiology, and Clinical Presentation
of Diabetes Mellitus
Executive summary
Diabetes mellitus (DM) is a metabolic disorder characterized and iden�fied by the presence
of persistent hyperglycemia.
The e�opathology of DM includes defects in insulin secre�on, insulin ac�on, or both, and
disturbances of carbohydrate, fat, and protein metabolism.
Type 1 diabetes (T1DM), type 2 diabetes (T2DM), and Gesta�onal Diabetes (GDM) are the
common types of DM.
T1DM usually presents with classical features of hyperglycemia including polyuria,
polydipsia, polyphagia, weight loss and generalized weakness.
T2DM and other forms of diabetes mellitus may remain asymptoma�c for quite a long
period resul�ng in late diagnosis and interven�on.
A significant propor�on of T2DM cases may present with one or more chronic
complica�ons.
Diabetes mellitus (DM) is a metabolic disorder characterized and iden�fied by the presence of
persistent hyperglycemia. Varying degrees of e�opathologies include principally defects in
insulin secre�on, insulin ac�on or both, and disturbances of carbohydrate, fat, and protein
metabolism.1 In recent �mes several other pathological pathways are recognized, especially in
type 2 diabetes (T2DM).
1.1 Epidemiology
1.1.1 Global trend
DM is now one of the most common noncommunicable diseases globally. It is an epidemic
in many developing and industrializing countries. At present, the total number of diabe�c
persons globally is nearly 537 million with a prevalence of 10.5% in the adult popula�on
(20 to 79 years). China and India hold the first and second posi�ons respec�vely having
140.9 and 74.2 million of total cases of diabetes. It is es�mated that this current number of
diabe�c persons is projected to reach 643 million by 2030, and 783 million by 2045. 2
In addi�on to diabetes, prediabetes also cons�tutes a major public health problem because of
its associa�on with an increased risk of DM and cardiovascular diseases (CVD). A total of 541
million (1 in 9) people are es�mated to have impaired glucose tolerance (IGT) and 319 million (1
in 18) people have impaired fas�ng glucose (IFG).2
- 2 -
1.1.2 Bangladesh Trend
At present, the total number of diabe�c people is nearly 13.1 million, with a prevalence being
14.2% in the adult popula�on (20 to 79 years). Almost all are T2DM. Bangladesh at present is
in 8th posi�on in the world by the total number of people with DM. By 2045, it is projected to
move to the 7th posi�on, with 22.3 million people with T2DM.2 Na�onal Noncommunicable
disease (NCD) Risk Factor Study 2022 reported 9.7% (15-69 years) DM in Bangladesh (Collected
by personal Communica�on).3
1.2 Classification1
Diabetes mellitus is classified based on clinical care into six types (Table 1). However, type 1
diabetes (T1DM), T2DM, and gesta�onal diabetes (GDM) are the common types of DM.
Table 1.1 Classifica�on of DM
Type 1 diabetes
Type 2 diabetes
Hybrid forms of diabetes
Slowly evolving immune-mediated diabetes of adults
Ketosis prone type 2 diabetes
Other specific types
Monogenic diabetes
Monogenic defects of β-cell func�on
Monogenic defects in insulin ac�on
Diseases of the exocrine pancreas (fibrocalculus pancreatopathy, pancrea��s,
trauma/pancreatectomy, neoplasia, cys�c fibrosis, hemochromatosis and others)
Endocrine disorders (Cushing’s syndrome, acromegaly, pheochromocytoma, glucagonoma,
hyperthyroidism, somatosta�noma and others)
Drug-or chemical-induced (glucocor�coids, thyroid hormone, thiazides, alpha-adrenergic
agonists, beta-adrenergic agonists, dilan�n, pentamidine, nico�nic acid, interferon-alpha etc.)
Infec�ons (congenital rubella, cytomegalovirus)
- 3 -
Uncommon specific forms of immune-mediated diabetes (insulin autoimmune syndrome,
an�-insulin receptor an�bodies, s�ff man syndrome)
Other gene�c syndromes some�mes associated with diabetes (Down syndrome,
Friedreich’s ataxia, Hun�ngton’s chorea, Klinefelter’s syndrome, myotonic dystrophy,
porphyria, Prader-Willi syndrome, Turner’s syndrome and others)
Unclassified diabetes
This category should be used temporarily when there is not a clear diagnos�c category
especially close to the �me of diagnosis of diabetes
Hyperglycemia first detected during pregnancy
Diabetes mellitus in pregnancy
Gesta�onal diabetes mellitus (GDM)
1.3 Criteria of different types of DM1, 2, 4
Table 1.2 Difference between T1DM, T2DM and GDM
Type 1 DM Type 2 DM GDM

Markers of beta cell Markers of beta cell Associated with
destruc�on may be destruc�on usually absent pregnancy
present Presents a�er 30 years of Placental hormones
Presents before 30 age antagonize maternal
years of age Body habitus - insulin
Body habitus - normal to obese/overweight More common if
wasted Symptoms are gradual & maternal age is >25 years
Symptoms are sudden & atypical Obesity/over-weight
classical More gene�c link favors the development
Less gene�c link; maybe Hyperosmolar of GDM
HLA linked hyperglycemic state (HHS) Family history of T2DM is
Ketoacidosis (DKA) is is more common a risk factor
more common Insulin reserve declines Ketosis may develop
Insulin reserve is very very slowly; can be Insulin is the treatment
low; insulin is treated with non-insulin of choice
mandatory for agents
treatment
- 4 -
1.4 Initial steps for classifying DM1
1. Confirm diagnosis of DM
2. Exclude secondary causes
3. Consider the following which may assist in differen�a�ng subtypes:
a. Age at diagnosis
b. Family history
c. Physical findings, especially the presence of obesity
d. Presence of features of metabolic syndrome
4. Note the presence or absence of ketosis or ketoacidosis
5. Perform diagnos�c tests if available (β-cell autoan�bodies, C-pep�de)
1.5 Pathophysiology1, 2, 4-6

1.5.1 Type 1 diabetes
It is mostly caused by autoimmune destruc�on of the beta cells in the pancreas, resul�ng in a
severe reduc�on in insulin produc�on. Gene�c suscep�bility, an environmental factor like viral
infec�on and autoimmunity, in combina�on, plays an important role in the development of
T1DM. Some T1DM cases are idiopathic in nature.
1.5.2 Type 2 diabetes

Insulin resistance and beta cell failure represent the main pathophysiologic defects in T2DM.
Subjects with T2DM are maximally insulin resistant and have lost approximately 50% of their
beta cell func�on. The degree of insulin resistance and beta cell loss defer from one type to
another type and that is why the presenta�on of T2DM is heterogeneous. Gradual loss of beta
cell func�on is characteris�c of T2DM over the course of �me. In addi�on, muscle (impaired
glucose disposal), liver (increased glucose produc�on), beta cell (reduced insulin produc�on),
fat cell (accelerated lipolysis), gastrointes�nal tract (incre�n deficiency/resistance), alpha cell
(hyperglucagonemia), kidney (increased glucose reabsorp�on), and brain (insulin resistance) –
all play important roles in the development of glucose intolerance in T2DM individuals.
Collec�vely, these eight pathways comprise the ominous octet.
- 5 -
1.5.3 Gestational diabetes mellitus
This type of diabetes is caused by placental hormones, namely beta hCG, human placental
lactogen, estrogen, progesterone, etc. antagonizing the ac�on of insulin.
1.6 Clinical presentation1, 2, 4, 6

The spectrum of presenta�on ranges from asymptoma�c to typical features.
Asymptoma�c cases are diagnosed by biochemical tests only. A vast majority of T2DM and
other types remain asymptoma�c over a prolonged period. Rou�ne check-up usually picks
up this form of DM. T1DM is always symptoma�c and shows classical features of
hyperglycemia.
Typical features of DM start with glycosuria, which begins a�er the blood glucose level has
gone above an individual's renal threshold for glucose. Features include polyuria,
polydipsia, polyphagia, weight loss and generalized weakness. These are mostly seen in the
presenta�on of T1DM, though not so common in other types.
Atypical manifesta�ons are non-specific, which include non-healing infec�on, infer�lity or
repeated pregnancy loss, pruritus vulvae, undue fa�gability etc. This is a common mode of
presenta�on in T2DM.
Specific complica�ons of DM may be present at the �me of diagnosis. In T2DM and other
forms of diabetes mellitus, presenta�ons may remain asymptoma�c for quite a long period
resul�ng in late diagnosis and interven�on. So significant propor�on of T2DM cases
presents with one or more chronic complica�ons. All T1DM cases are usually diagnosed
before the development of chronic complica�ons.
1.7 Prediabetes1, 2, 4
IGT (impaired glucose tolerance) and IFG (impaired fas�ng glucose) are referred to as
'Prediabetes'. Persons with prediabetes have a high risk of developing DM (25% of IFG and 30%
of IGT cases become diabe�c over �me) and CVD. Any type of DM can pass through the stages
of prediabetes, but it is most obvious in T2DM. These persons are treated by lifestyle
modifica�ons; drugs may be used where indicated. About 40% of IFG and 30% of IGT cases
may revert to normal if the proper interven�on can be given.
- 6 -
References
1. Classifica�on of diabetes mellitus. Geneva: World Health Organiza�on; 2019.
h�p://apps.who.int/iris.
2. Interna�onal Diabetes Federa�on Diabetes Atlas, 10th edi�on, Brussels: Interna�onal
Diabetes Federa�on, 2021.
3. Bangladesh NCD risk factor survey 2022.
4. American Diabetes Associa�on Professional Prac�ce Commi�ee; Classifica�on and
Diagnosis of Diabetes: Standards of Medical Care in Diabetes. Diabetes Care 2022; 45:
S17–S38.
5. De Fronzo RA. From the triumvirate to the ominous octet: a new paradigm for the
treatment of type 2 diabetes mellitus. Diabetes. 2009; 58:773-95.
6. Diabetes Care BADAS Guideline. h�ps://dab-bd.org/Diabetes_ Care_ BADAS_ Guideline_
2019.pdf. (last accessed May 2022).
- 7 -
Chapter-2
Screening and Diagnosis

of
Diabetes Mellitus
- 8 -
CHAPTER-2
Screening and Diagnosis of Diabetes Mellitus
Executive summary
Procedures for documen�ng glucose intolerance includes: 2-sample oral glucose tolerance
test (OGTT), fas�ng plasma glucose (FPG), HbA1c and random plasma glucose (RPG) with
symptoms.
Screening prediabetes/ diabetes should be considered in all asymptoma�c adults ≥30 years
of age, adults <30 years of age who are over-weight/obese (BMI ≥23 kg/m2) and adults <30
years of age with BMI <23 kg/m2 but have one or more risk factors.
Screening should be considered a�er onset of puberty or a�er 10 years of age in all
asymptoma�c children and adolescents with BMI ≥85 th percen�le and before 10 years of
age with BMI ≥85th percen�le and who have addi�onal risk factors for diabetes.
If results are normal, tes�ng should be repeated at 1-year interval or as relevant.
Testing for prediabetes/ diabetes should be considered in all women planning pregnancy.
All women should be screened at the first antenatal visit with 3 sample 75 gm OGTT, if
nega�ve, re-screen during 24-28 weeks of gesta�on.
Screening and diagnosis of glucose intolerance in various popula�on can be made with
different clinical scenario and laboratory tests.
2.1 Screening for prediabetes and diabetes

2.1.1 Screening for prediabetes and diabetes in adults
Tes�ng for prediabetes/ diabetes should be considered in all asymptoma�c adults ≥ 30
years of age (even if without risk factors).1
Tes�ng for prediabetes/ diabetes should be considered in all asymptoma�c adults <30
years of age who are over-weight/obese (BMI ≥23 kg/m2).1-3
Tes�ng for prediabetes/ diabetes should be considered in all asymptoma�c adults <30
years of age with a BMI <23 kg/m2 and who have one or more of the following risk factors:1
o First-degree rela�ve with diabetes
o History of GDM
o History of CVD with Hypertension (140/90 mmHg or on therapy for hypertension)
o HDL cholesterol level <35 mg/dL and/or a triglyceride level >250 mg/dL
o Women with polycys�c ovary syndrome
o Physical inac�vity
- 9 -
Immediate tes�ng is required in symptoma�c cases. 1
Tes�ng is advised in all pa�ents with HIV. 1
If results are normal, tes�ng should be repeated at 1 year interval, with considera�on of more
frequent tes�ng depending on ini�al results, deteriora�ng risk status and appearance of
symptoms. People with prediabetes (HbA1c >5.7-6.4%, IGT or IFG) and women who were
diagnosed with GDM should be tested yearly.
2.1.2 Screening for prediabetes and diabetes in children

Tes�ng for prediabetes/diabetes should be considered a�er the onset of puberty or a�er
10 years of age, whichever occurs earlier, in all asymptoma�c children and adolescents
who are over-weight (BMI ≥85th percen�le) or obese (BMI ≥95th percen�le). 1
Tes�ng for prediabetes/diabetes should be considered before 10 years of age in
asymptoma�c children and adolescents who are over-weight (BMI ≥85th percen�le) or
obese (BMI ≥95th percen�le) and who have addi�onal risk factors for diabetes: 1
o History of diabetes or GDM during the child’s gesta�on
o Both parents with diabetes
o Family history of type 2 diabetes in first- or second-degree rela�ve
o Signs of insulin resistance or condi�ons associated with insulin resistance (acanthosis
nigricans, hypertension, dyslipidemia, polycys�c ovary syndrome, or small-for-
gesta�onal-age birth weight)
Immediate tes�ng is required in symptoma�c cases. 1
If results are normal, tes�ng should be repeated at 2-year intervals, with considera�on of more
frequent tes�ng depending on ini�al results, deteriora�ng risk status or appearance of
symptoms. Children with prediabetes should be tested yearly.
2.1.3 Screening for diabetes in women planning pregnancy and pregnant

Tes�ng for prediabetes/ diabetes should be considered in all women planning pregnancy.1
If preconcep�on test is nega�ve, test all women at the first antenatal visit with 3 sample
75 gm OGTT.1
- 10 -
If early screening is nega�ve, screening should be done at 24-28 weeks of gesta�on with 3
sample 75 gm OGTT.1
Women with GDM should be tested with 2 sample 75 gm OGTT and non-pregnant
diagnos�c criteria at 4-12 weeks postpartum, preferably at 6th week considering
vaccina�on schedule of children in Bangladesh.1
2.1.4 Screening for T1DM

Plasma glucose rather than HbA1c should be used to diagnose the acute onset of T1DM in
individuals with symptoms of hyperglycemia.1
Screening for T1DM risk with a panel of autoan�bodies (autoan�bodies to islet cell, insulin,
GAD, Zinc transporter) can be done in first-degree family members of a proband with T1DM
where facility is available.1
2.1.5 Screening in special populations

In those with hemoglobinopathies, annual screening with standard OGTT should begin at
10 years of age. There is limited role of HbA1c in this se�ng. 4
A�er organ transplanta�on, tes�ng with OGTT should be performed once the pa�ent is
stable on immunosuppressive therapy and there is no infec�on. 1
2.2 Diagnosis of prediabetes and diabetes

Diagnosis is based on documenta�on of glucose intolerance in an individual. Procedures for
documen�ng glucose intolerance include:
1. Oral glucose tolerance test (OGTT) – gold standard test
2. Fas�ng plasma glucose (FPG)
3. HbA1c (Glycated hemoglobin)
4. Random plasma glucose (RPG)
2.2.1 OGTT (gold standard test)

Plasma glucose level is determined at fas�ng and 2 hours a�er 75 grams (1.75-gram glucose/kg
body weight, up to maximum 75-gram glucose for children) of oral glucose drink. It classifies a
- 11 -
person as a diabe�c, IGT (impaired glucose tolerance), IFG (impaired fas�ng glucose) or
normal.1,5
OGTT procedure5
Person should take unrestricted diet containing at least 150 grams of carbohydrate daily
for at least previous 3 days.
The test should be done in the morning a�er 8-14 hours of overnight fast (Preferably
before 9 am).
A fas�ng blood sample prior to glucose drink is collected.
An oral glucose load of 75-gram of anhydrous glucose for adult (1.75-gram glucose/kg body
weight, up to maximum 75-gram glucose for children) is given in 250-300 ml of water. The
drink must be completed within 5 minutes.
A second blood sample is collected at 120 th minute a�er the glucose drink.
If glucose is not es�mated immediately then the blood sample may be preserved with
sodium fluoride (6 mg/ml whole blood), blood should be centrifuged, and plasma
separated and frozen un�l es�ma�on.
Smoking, tea or physical stress is not allowed during the test.
2.2.2 FPG
By fas�ng plasma glucose level, a person can be labeled as a diabe�c, but cannot exclude
diabetes.1,5
2.2.3 HbA1c
HbA1c is now increasingly being used in diagnosis of diabetes. The test must be highly
standardized for using it in this purpose.1,5
2.2.4 RPG
No prepara�on is required for this procedure. Plasma glucose levels are es�mated from a
sample irrespec�ve of last meal. RPG, in presence of classical symptoms of hyperglycemia or
hyperglycemic crisis can confirm diabetes.1
- 12 -
Table 2.1 Diagnos�c criteria for prediabetes (IFG and IGT) and diabetes mellitus for non-
pregnant adults and children1,5
IFG IGT DM
Fas�ng plasma glucose 6.1-<7.0 mmol/L <7.0 mmol/L ≥7.0 mmol/L
(110-<126 mg/dL) (<126 mg/dL) (≥126 mg/dL)
And And Or
2–h plasma glucose <7.8 mmol/L 7.8-<11.1 mmol/L ≥11.1 mmol/L
during OGTT (<140 mg/dL) (140-<200 mg/dL) (≥200 mg/dL)
And/or Or
HbA1c 5.7- 6.4% ≥6.5%
(39-47 mmol/mol) (≥48 mmol/mol)
Or
Random plasma -- -- ≥11.1 mmol/L
glucose*
NB: *In presence of classical symptoms of hyperglycemia (polyuria, polydipsia, polyphagia,

weight loss and generalized weakness) or hyperglycemic crisis.
Table 2.2 Diagnos�c criteria for hyperglycemia in pregnancy 6
Gestational diabetes mellitus Diabetes in pregnancy

(GDM) (DIP)
FPG 5.1-<7.0 mmol/L >7 mmol/L
(92-<126 mg/dL) (126 mg/dL)
1-hr PG at OGTT ≥10.0 mmol/L --
(180 mg/dL)
2-hr PG at OGTT 8.5-<11.1 mmol/L ≥11.1 mmol/L
(153-<200 mg/dL) (200 mg/dL)
NB: Diagnosis is made when any one of the plasma glucose values is met. Performed
with a 3-step 75-gm OGTT at any �me in pregnancy. All values are venous plasma glucose.
- 13 -
References
1. American Diabetes Associa�on Professional Prac�ce Commi�ee; Classifica�on and
Diagnosis of Diabetes: Standards of Medical Care in Diabetes. Diabetes Care 2022; 45 (1):
S17–S38.
2. American Diabetes Associa�on. Standards of Medical Care in Diabetes. Diabetes Care
2022;45(1):90-92.
3. Interna�onal Diabetes Federa�on Diabetes Atlas, 10th edi�on, Brussels: Interna�onal
Diabetes Federa�on, 2021.
4. Cappellini MD, Cohen A, Porter J, et al., editors. Guidelines for the Management of
Transfusion Dependent Thalassemia (TDT). 3rd Edi�on. Nicosia (CY): Thalassemia
Interna�onal Federa�on; 2014.
5. Defini�on and diagnosis of diabetes mellitus and intermediate hyperglycemia: report of a
WHO/IDF consulta�on. Geneva, Switzerland: WHO Document Produc�on Services; 2006.1-
46.
6. Diagnos�c Criteria and Classifica�on of Hyperglycemia First Detected in Pregnancy.
Geneva, Switzerland: WHO Press; 2013.1-63. Report no. WHO/NMH/MND/13.2.
- 14 -
Chapter-3
Treatment
of
Diabetes Mellitus
- 15 -
CHAPTER-3
Treatment of Diabetes Mellitus
Executive summary
Comprehensive medical assessment is impera�ve for people with DM.
In the management of diabetes diet and exercise are mandatory for all individuals.
Insulin is the only pharmacotherapy for T1DM on the other hand various classes of
medica�ons including sulfonylureas, megli�nides (non-sulfonylureas), biguanides,
thiazolidinediones (TZDs), alpha-glucosidase inhibitors, glucagon-like pep�de-1 (GLP1)
receptor agonists, dipep�dyl pep�dase-4 (DPP4) inhibitors, sodium glucose cotransporter-
2 (SGLT2) inhibitors and insulin can be used in T2DM.
The presence of complica�ons or comorbidi�es such as ASCVD, CKD, and heart failure also
has an important role in determining therapy.
Monitoring of glycemic control by SMBG and CGM are important components of diabetes
management.
Treatment of DM is always individualized. T1DM always requires insulin but the

management of T2DM is of great challenge and require appropriate decision making. Not
only the glycemic control but CVD risk, presence of comorbidi�es and complica�ons need
to be considered when choosing a par�cular an�diabe�c agent.
Table 3.1 Factors to be considered before selec�on of an�diabe�c agent 1,2
Type of DM Degree of hyperglycemia

Age of the person Job and occupa�on/lifestyle of the person
Body weight/BMI Previous an�diabe�c agents (if on any)
Associated condi�ons, e.g. Caregiver support
acute/chronic complica�ons/illnesses, Poten�al for side effects like hypoglycemia
pregnancy/lacta�on, major surgery, life risk
expectancy etc.
Socio-economic condi�on/cost of
medica�on
Personal preference
- 16 -
Table 3.2 Target of diabetes management (in non-pregnant adult)2
Blood (plasma) glucose Fas�ng/pre-meal <7.0 mmol/L

Post-meal <10.0 mmol/L (1-2 hr a�er beginning of meal)
HbA1c <7%
(Less stringent, e.g. 7-8% in elderly with mul�ple comorbidi�es)
Blood lipids LDL cholesterol <100 mg/dL (<70 mg/dL in H/O CVD)
HDL cholesterol >40 mg/dL (male)
>50 mg/dL (female)
Triglyceride <150 mg/dL
Blood pressure Systolic <130 mm of Hg
Diastolic <80 mm of Hg
BMI BMI <23 kg/m2
Waist circumference (WC) WC <90 cm (male)
<80 cm (female)
Educa�on and empowerment regarding lifestyle changes, SMBG and treatment adjustment
should also be targeted
NB: Target of glycemic control may be individualized considering individual factors.
3.1 Treatment regimen and monitoring

3.1.1 Non-pharmacological
Lifestyle modifica�on includes medical nutri�on therapy and exercise.
Medical nutrition therapy

An individualized medical nutri�on therapy preferably by a registered die��an, is
recommended for all people with diabetes and prediabetes. Typical composi�on of a
balanced diet should be carbohydrate 50%, protein 10-20%, fat<30%. Meal plans should
be individualized while keeping total calorie and metabolic goals in mind.
- 17 -
Table 3.3 Factors related to medical nutri�on therapy
Points Description
Weight loss >5% by combina�on of reduc�on of calorie intake and increased
physical ac�vity, benefits over-weight or obese adults with T2DM
and prediabetes.
Nutrient-dense Sources that are high in fiber, including vegetables, fruits, legumes,
carbohydrate whole grains, as well as dairy products should be emphasized.
Sugar-sweetened People with DM and those at risk are advised to avoid sugar-sweetened
beverages beverages (including fruit juices) in order to control glycemia, weight. It
also reduces their risk for cardiovascular disease and fa�y liver.
Protein Diet should contain sufficient protein from animal and plant sources.
Dietary fat Diet rich in monounsaturated and polyunsaturated fats may be
considered to improve glucose metabolism and lower cardiovascular
disease risk. Foods rich in long-chain n-3 fa�y acids, such as fa�y fish
(EPA and DHA) and nuts and seeds (ALA) are recommended to prevent
or treat cardiovascular disease.
Salt consump�on As for the general popula�on, people with diabetes should limit salt
consump�on to 5 gm/day.
Non-nutri�ve Non-nutri�ve sweeteners can reduce overall calorie and carbohydrate
sweeteners intake but overall, people are encouraged to decrease both sweetened
and non-nutri�ve sweetened beverages and to use other alterna�ves,
with an emphasis on water intake.
Dietary There is no clear evidence that dietary supplementa�on with vitamins,
supplementa�on minerals (such as chromium and vitamin D), herbs, or spices (such as
j
cinnamon or aloe vera) can improve outcomes in profile with diabetes.
Meal frequency Three main meal and 2 snacks with a bed �me snack for those having
mul�ple daily injec�on or have a tendency for midnight hypoglycemia.
Calorie allowance Calorie Allowence = Ideal body weight x calorie factor
Ideal body weight = height in cm - 100
Calorie factor varies from 20 to 45 according to BMI and physical ac�vity
status.
- 18 -
Exercise/physical activity3
Adults with diabetes should perform150 minutes or more of moderate intensity
aerobic ac�vity per week, spread over at least 5 days/week, with no more than 2
consecu�ve days without ac�vity.
Shorter dura�ons (minimum 75 min/week) of moderate intensity or interval training
may be sufficient for younger and more physically fit individuals.
Adults with diabetes should engage in 2-3 sessions/week of resistance exercise on
non-consecu�ve days.
All adults and par�cularly those with type 2 diabetes, should decrease the amount of
�me spent in daily sedentary behavior, prolonged si�ng should be interrupted every
30 minutes.
Physical ac�vity or exercise is encouraged to do same �me in a day.
- 19 -
Table 3.4 Some prac�cal points on exercise2
Warm up Muscle stretching Main exercise Cool down

Time 5-10 minutes 5-10 minutes 30 minutes 5-10 minutes
Type of Aerobic ac�vity Gentle muscle Moderate to high Low intensity
exercise (e.g. walking) at stretching intensity exercise ac�vity
low intensity
Type and dura�on of exercise may vary in some special instances as shown in the following table.
Table 3.5 Exercise in special situa�ons2

Condition Exercise recommendation
Peripheral neuropathy, Should not engage in repe��ve weight bearing exercises, e.g.
loss of protec�ve prolonged walking, treadmill, jogging etc. as these ac�vi�es may
sensa�on, Charcot's joint result in blistering, ulcera�on and fracture.
and osteoarthri�s of back Non-weight-bearing exercises, e.g. swimming, cycling, rowing, etc.
and knee may be be�er.
Prolifera�ve and Strenuous ac�vity may precipitate vitreous hemorrhage or
moderate to severe trac�onal re�nal detachment; they should avoid anaerobic
non-prolifera�ve exercise and physical ac�vity that involves straining, jarring or
diabe�c re�nopathy VaIsaIva-like maneuvers (e.g. weight li�ing, boxing, heavy
compe��ve sports etc).
In these persons low impact exercises like swimming (but not
diving), walking or sta�onary cycling may be recommended.
Stable coronary heart Perform moderate intensity exercise.

disease
Uncontrolled Withhold exercise un�l control of blood pressure.
hypertension
Symptoma�c Exercise should be postponed If blood glucose goes >16.7
hyperglycemia/ketosis mmol/L. If blood glucose is <3.9 mmol/L the person should
or hypoglycemia take extra 15-30 grams carbohydrate before exercise.
Significant acute illness Should not exercise during this illness.
or uncompensated
major chronic illnesses
During pregnancy Moderate exercise (e.g. walking at moderate speed for 30
minutes a day at a �me or in divided fashion) is advised if there
is no obstetric contraindica�on.
Bed-ridden persons Physiotherapy, passive movement and posture change.
- 20 -
Diabetes management algorithm in uncomplicated, non-pregnant adults with type 2 diabetes (based on glycemic status)
NB: LS - Lifestyle
Target of glycemic status should be individualized
FBG <10.0 mmol/l and /or HbA1c <8.5% FBG 10-<14 mmol/l and /or HbA1c 8.5- <10% FBG ≥14 mmol/l and /or HbA1c ≥10% and /or
and /or RBG <12mmol/l and /or RBG 12-<18 mmol/l RBG ≥18 mmol/l with or without symptoms
LS + Metformin Asymptomatic Symptomatic

Target
3.1.2 Pharmacological therapy
FBG / Premeal <7.0 mmol/L

2hABF/Postmeal <10.0 mmol/L
LS + Metformin +
Initial treatment
LS + Insulin (Premix/ Basal/Split-mix) ± Metformin HbA1c <7 %
Sulphonylurea or other agent
Consider
If HbA1c ≥7% on treatment Age
Body weight
- 21 -
CVD
Add 2nd agent Add 3rd agent
Titration and optimization CKD
(oral/inj) of (oral/inj) of different
Hypoglycemia
different action action
UTI
G.I upset
If HbA1c ≥7% on treatment
Cost
Other agents
Figure 3.1 Type 2 diabetes management algorithm

(Adapted from Diabetes Care, BADAS Guideline 2019)
• Add 3rd agent (oral/inj) of different • Add 4th agent (oral/inj) of different DPP4-I
action Intensification of
action Insulin regimen
AG-I
Follow-up treatment
• Insulin is the best option to add • Insulin is the best option to add TZD
(Premix/ Basal/Split-mix); omit SU (Premix/ Basal/Split-mix); omit SU GLP 1-RA
SGLT2-I
If HbA1c ≥9% 3 months after initiation of treatment (at any point) - add/start Insulin
an�diabe�c agent is always individualized and may vary in same person in different situa�on.
individual and drug factors are considered while choosing an an�diabe�c agent. Selec�on of
Oral drugs, insulin and other injectable agents are used for management of diabetes. Several
3.2 Oral antidiabetic drugs (OADs)
Oral drugs are not recommended in type 1 DM, and during pregnancy and lacta�on.
Table 3.6 Different classes of OADs
Class Drugs
Sulfonylureas Glibenclamide
(s�mulate insulin secre�on from beta cells) Glipizide
Gliclazide
Glimepiride
Non-sulfonylureas Repaglinide
(s�mulate insulin secre�on from beta cells) Nateglinide
Biguanides Me�ormin
(reduce insulin resistance)
Thiazolidinediones Pioglitazone
(insulin sensi�zers, act via PPARʏ receptor s�mula�on) Rosiglitazone
Alpha-glucosidase inhibitors Acarbose
(inhibit glucose absorp�on from intes�nal brush border) Miglitol
Voglibose
DPP4 inhibitors Vildaglip�n
(inhibit DPP4 enzyme and increase half-life of GLP1) Sitaglip�n
Linaglip�n
Saxaglip�n
Aloglip�n
SGLT2 inhibitors Dapagliflozin
(inhibit glucose reabsorp�on from proximal convoluted tubule) Canagliflozin
Empagliflozin
Ertugliflozin
Oral GLP1 receptor agonists Semaglu�de
(s�mulate glucose dependent insulin secre�on from beta cells,
suppress glucagon secre�on alpha cells and delay gastric emptying)
- 22 -
Table 3.7 Selec�on issues of an oral agent
Drug Advantages Hazards Limitations

Sulfonylureas Potent Hypoglycemia, Impaired hepa�c, renal
Reduce pre- & post-prandial BG weight gain func�on
Avoid long ac�ng SU in CKD
Non- Less hypoglycemia Weight gain Impaired hepa�c, renal
sulfonylureas Reduce post-prandial BG func�on
Biguanides Improve insulin sensi�vity GI upset, lac�c Impaired renal func�on
Weight friendly acidosis eGFR <45 - Do not ini�ate
Reduce pre- (mostly) & post- eGFR <30 - contraindicated
prandial BG
Favorable effect on lipid & NAFLD
Thiazolidined Improve insulin sensi�vity Weight gain, Heart failure
i-ones Reduce pre- (mostly) & post- fluid reten�on Risk of bone fractures
prandial BG Bladder cancer
Favorable effect on lipid & NAFLD
Alpha- Weight friendly GI upset Impaired hepa�c func�on
glucosidase Reduce post-prandial BG Inflammatory. bowel disease
inhibitors Malabsorp�on states
DPP4 inhibitors Weight friendly GI upset, upper Impaired renal func�on
Reduce pre- & post-prandial RTI, pancrea��s Vildaglip�n:
(mostly) BG eGFR <50 - 50% of max. dose
eGFR >50 - normal dose
Sitaglip�n:
eGFR <30 - 25% of max. dose
eGFR 30-60 - 50% of max.
dose
SGLT2 inhibitors Weight friendly UTI, genital Impaired renal func�on
Reduce pre- & post-prandial BG fungal infec�on eGFR <30 - contraindicated
GLP1-RAs Weight reduc�on GI upset, Personal or family history of
Cardiovascular safety pancrea��s MTC, & in MEN-2
NB: NAFLD - Non-alcoholic fa�y liver. eGFR ml/min/1.73m2. MTC - medullary thyroid cancer.
MEN-2 - mul�ple endocrine neoplasia syndrome type 2.
Special note
Two secretagogues cannot be prescribed together.
One secretagogue cannot be replaced by other in case of failure of one secretagogue to
achieve glycemic target.
Secretagogue needs to be discon�nued when twice daily insulin is started.
- 23 -
Table 3.8 Ini�a�on and dose �tra�on of OADs2,4,5
Drug Starting daily dose Maximum daily dose Time required
for reasonable
effect
Glibenclamide 1.25-2.5 mg x 1; 30 min ac 20 mg (in 1-2 doses)
Glipizide 2.5 mg x 1; 30 min ac 40 mg (in 1-2 doses)
Gliclazide 40 mg x 1;30 min ac 320 mg (in 1-2 doses) 2 weeks
MR/ExR-120 mg (in 1 dose)
Glimepiride 1 mg x 1 6 mg (in 1 dose)
Repaglinide 0.5 mg x 3; 15 min ac 12 mg (in 3 doses) 1-2 weeks
Nateglinide 60 mg x 3; 15 min ac 360 mg (in 3 doses)
Me�ormin 500 mg x 1; pc; build up dose 2500 mg (in 2-3 doses) 4 weeks
weekly ExR-2000 mg (in 1 dose)
Pioglitazone 15 mg x 1; morning 45 mg (in 1 dose) 4-6 weeks
Rosiglitazone 4 mg x 1 (or 2 mg x 2) 8 mg (in 1-2 doses)
Acarbose 25-50 mg X 1-3; within 300 mg (in 3 doses)
Miglitol meal; build up dose weekly 6 weeks
Voglibose 0.2 mg x 1-3; pc 0.9 mg (in 3 doses)
Sitaglip�n 100 mg x 1 100 mg (in 1 dose)
Vildaglip�n 50 mg x 2 100 mg (in 2 doses)

Linaglip�n 5 mg x 1 5 mg (in 1 dose) 12 weeks
Saxaglip�n 2.5 mg x 1 5 mg (in 1 dose)
Aloglip�n 25 mg x 1 25 mg (in 1 dose)
Dapagliflozin 5 mg x 1, morning 10 mg (in 1 dose)
Canagliflozin 100 mg x 1, morning 300 mg (in 1 dose) 4-12 weeks
Empagliflozin 10 mg x 1, morning 25 mg (in 1 dose)
Ertugliflozin 5 mg x 1, morning 15 mg (in 1 dose)
Semaglu�de 3 mg daily 14 mg (once daily) 4 weeks
NB: ac - before meal. pc - a�er meal.
- 24 -
3.3 Insulin and other injectable agents
Insulin is the most potent pharmacological agent in the management of all types of diabetes.
Table 3.9 Classifica�on of insulin

Insulin type Onset of action Peak Duration of action Appearance
Bolus (prandial) insulin
Short-ac�ng (Regular) insulin 30 min 2-3 hr 6.5 hr Clear
Rapid-acting insulin analogue
Insulin Lispro 10-15 min 1-2 hr 3.5-4.75 hr Clear
Insulin Faster Aspart <5 min 1 hr 3-5 hr Clear
Insulin Aspart 10-15 min 1-1.5 hr 3-5 hr Clear
Insulin Glulisine 10-15 min 1-1.5 hr 3-5 hr Clear
Basal insulin
Intermediate-ac�ng (NPH) 1-3 hr 5-8 hr Upto 18 hr Cloudy
Long-ac�ng insulin analogue
Insulin Detemir 90 min No peak 24 hr Clear
Insulin Glargine 90 min No peak 24 hr Clear
Insulin Degludec 90 min No peak 42 hr Clear
Premixed insulin (30/70,50/50,25/75)
Biphasic Human Insulin 30 min 2-8 hr Upto 24 hr Cloudy
Biphasic Insulin Aspart 10-20 min 1-4 hr Upto 24 hr Cloudy
Biphasic Insulin Lispro 10-20 min 1-4 hr Upto 24 hr Cloudy
Coformulation (30/70)
Insulin Degludec + 30-90 min No peak Beyond 24 hr Clear
Insulin Aspart 10-20 min 40-90 min
Table 3.10 Dose adjustment of injectable GLP1-RAs
Drug Dose
Liraglu�de 0.6 mg daily, increase to 1.2 mg a�er 1 week; max. dose 1.8 mg
Dulaglu�de 0.75 mg daily, increase to 1.5 mg a�er 4 week; max. dose 4.5 mg
Semaglu�de 0.25 mg daily, increase to 0.5 mg a�er 4 week; max. dose 1.0 mg
- 25 -
Table 3.11 Insulin regimens4,5
Regimen Description
Basal only regimen • NPH given once or twice daily or basal analogue given once daily
• Common regimen of ini�a�on of insulin therapy
• To make the person confident about self injec�on of insulin
Twice daily injections

Premixed • Most commonly prescribed insulin regimen
• Convenient
• Difficult to achieve glycemic control at all points of day
• Risk of hypoglycemia when meal �me is irregular
Coformula�on Convenient and allows flexibility in regard to meal

Split-mixed • Two/three �mes short ac�ng added to twice daily intermediate ac�ng
insulin
• Easier to achieve glycemic control at all points of day
• Need for mul�ple injec�ons
• Dose adjustment is some�mes difficult for some persons
Multiple daily injections

Basal Plus • Combina�on of basal insulin with one or more doses of short
ac�ng insulin as needed
• Offers more meal �me flexibility
Basal-bolus • Long ac�ng insulin analogue given at bed�me as basal dose and
rapid ac�ng insulin analogue given before each meal as bolus doses
• Ideal insulin regimen as it mimics normal physiological insulin
secre�on pa�ern
• This is very flexible and ideal for those who are very ac�ve and meal
�me is irregular
• Need for mul�ple injec�ons
Continuous subcutaneous Insulin pump, delivering insulin con�nuously as basal, with person
insulin infusion (CSII) ac�vated boluses with meals
Intravenous insulin DKA, HHS, cri�cal illness, prolonged NPO, TPN, periopera�ve period,
infusion during delivery etc.
3.3.1 Indications of insulin

Type 1 DM
Severe acute complica�on/illness e.g. MI, acute infec�on
Uncompensated chronic complica�on or illness
Pregnancy and lacta�on
- 26 -
At least 3-5 months prior to planned concep�on
Major surgery
OAD failure
Poor glycemic status
o HbA1c >10%
o FBS >14 mmol/L, RPG >18 mmol/L (with or without symptom)
o HbA1c >7% in spite of 50% of maximum dose of SU and maximum tolerable dose of
sensi�zer
o Symptoma�c hyperglycemia
3.3.2 How to start and adjust insulin3,4

1. Start with 0.2-0.5 unit/kg/day.
2. Premixed or coformula�on: Start with two third of the total calculated dose in the morning
and one-third at the evening (To start at a low dose with gradual up or down �tra�on).
3. Split-mixed: Two third of the total dose will be intermediate ac�ng and one third short
ac�ng. Among this two third dose in morning and one third dose at evening.
4. Basal insulin of 10 unit/day or 0.1-0.2 unit/kg/day. Fixing the fas�ng first. If postprandial
s�ll not within target, add bolus insulin 4 unit/day or 10% of basal dose.
5. Increase dose by 2-4 units every 3 days to reach the target.
6. Decrease dose by 2-4 units if blood sugar is below the target.
3.3.3 Continuous subcutaneous insulin infusion (CSII) pump

Con�nuous subcutaneous insulin infusion is a mode of delivering intensive insulin therapy,
which usually leads to improved glycemic control and reduced glycemic fluctua�on. It is a
ba�ery operated, portable, programmable pump to con�nuously deliver rapid-ac�ng insulin
via an infusion set inserted subcutaneously. Insulin pump is an alterna�ve to treatment with
mul�ple daily injec�on. Children with T1DM having mul�ple episodes of hypoglycemia or
uncontrolled diabetes requiring mul�ple daily injec�on and T2 DM requiring high dose of
insulin (>10 unit/kg) and not achieving glycemic target are candidates for CSII.
- 27 -
3.3.4 Insulin injection technique1
Injec�ons are given into the deep subcutaneous �ssue at 45-900 angle by two-finger pinch
of skin. The pinch is recommended to ensure a strict subcutaneous injec�on; avoiding
intramuscular injec�on. Injec�ons can be given perpendicularly without li�ing a skin fold
when needles are smaller and there is enough subcutaneous fat. Needles should be
inserted full, otherwise there is a risk of intradermal injec�ons. A wait of 15 seconds a�er
pushing the plunger helps to ensure complete expulsion of insulin through the needle,
especially in pens. Cleaning or disinfec�on of skin is advisable, but may not be necessary
unless hygiene is a real problem.
Vials (also the pen devices) of cloudy insulin must always be gently rolled (not shaken) 10-
20 �mes, to mix the insulin suspension. When two insulins are drawn (e.g. regular insulin
is mixed with NPH), the regular insulin is to be drawn before the intermediate ac�ng one.
The mixture must be administered immediately.
Abdomen is the preferred site when faster and uniform absorp�on is required; it is less
affected by muscle ac�vity or exercise. Front and lateral aspects of thigh is the preferred
site for slower absorp�on of longer ac�ng insulin. Lateral aspect of upper arm is another
site, but assistance is required for injec�on. The lateral upper quadrant of the bu�ocks is
used less o�en. Rota�on of injec�on sites are important within the same area of injec�on.
3.3.5 Storage of insulin1

Insulin must never be frozen. Direct sunlight or warming (e.g. in hot climates) damages insulin.
Insulin should not be used if there is change in appearance (clumping, fros�ng, precipita�on
or discolora�on). Unused insulin should be stored in a refrigerator (4-80 C) to retain its potency
up to expiry date. When in use, the insulin can be kept in room temperature (if not too hot)
without much loss of efficacy. But it retains its potency much be�er if kept in refrigerator. In
hot climates where refrigera�on is not available, cooling jars, earthenware pitcher or cool wet
cloth around the insulin container will help to preserve ac�vity.
3.4 Glycemic monitoring

3.4.1 Self blood glucose testing (SMBG)
To be done frequently (preferably once /twice weekly covering pre-meal, post-meal) in
persons who are on mul�ple dose insulin regimen or insulin pump, especially in T1DM and
pregnancy. For others it is to be done as required according to clinical situa�ons.
- 28 -
3.4.2 HbA1c
Glycated hemoglobin is formed by non-enzyma�c condensa�on of glucose with the
globin component of hemoglobin. This generally reflects glycemic status over the
preceding 2-3 months. The target of HbA1c is <7%. HbA1c guides change in the therapeu�c
regimen.
HbA1c test should be done at least two �mes a year in those who are mee�ng treatment
goals (and who have stable glycemic control) and quarterly in persons whose therapy
has changed or who are not mee�ng glycemic goals.
RBC turnover (blood loss, hemolysis, blood transfusion, pregnancy, etc.) and
hemoglobin variants must be considered while tes�ng HbA1c.
Result may vary if not done from a standardized lab.
3.4.3 Continuous glucose monitoring (CGM)

Con�nuous glucose monitoring automa�cally monitors blood glucose throughout the day and
night. A CGM works through a �ny sensor inserted in skin, usually on abdomen or arm. The
sensor measures inters��al glucose level. It measures glucose every few minutes and gives real
�me update. While calcula�ng the report of CGM the percentage of �me a person’s blood
sugar is found between 4.0-10.0 mmol/L is measured and this measured �me is designated as
Time in Range. The target of �me in range to keep >70% (17hours).
3.5 Comprehensive medical evaluation for people with DM

Components of comprehensive diabetes medical evalua�on at ini�al, follow up and annual
visits includes: a) past medical and family history, b) social history, c) medica�on and
vaccina�on, d) screening of psychosocial condi�ons, educa�onal supports, nutri�onal support,
pregnancy planning, e) physical examina�on, f) laboratory and imaging inves�ga�ons and g)
planning for achieving glycemic and other metabolic targets.
- 29 -
Table 3.12 Components of comprehensive medical evalua�on3
Past medical, age and onset of symptoms, personal history, history of diabetes of
personal and family first-degree family members, family history of autoimmune
history disorders, history of comorbidi�es, presence of macrovascular and
microvascular complica�ons, hemoglobinopathies, anemia,
hypertension, dyslipidemia, hyperuricemia, PCOS, subfer�lity etc.
Social history assessment of ea�ng pa�ern, weight changes, physical ac�vity,
sleep pa�ern, use of tobacco, alcohol and substance use and social
circumstances etc.
Medica�on and history of medica�on adverse effects/ allergy, use of
vaccina�on complementary and alterna�ve medicines, vaccina�on history and
need, assessment of use of health apps, educa�on portals, glucose
monitoring devices etc.
Educa�on supports Assessing diabetes self-management educa�on and supports,
iden�fying need to implement educa�on support and to overcome
barriers.
Screening of Screening for anxiety, depression, cogni�ve func�on, pre-pregnancy
psychosocial and pregnancy planning.
condi�ons,
nutri�onal support,
pregnancy planning
Physical examina�on Height, weight, BMI, pubertal development, blood pressure (BP),
skin, thyroid examina�on, fundoscopy, foot examina�on, others as
relevant.
Laboratory and HbA1c, if not performed within past 3 months, If not performed
imaging within past year: fas�ng lipid profile, liver func�on test, spot
inves�ga�ons albumin-to-crea�nine ra�o, serum crea�nine and eGFR, thyroid
func�on test, serum electrolyte, serum vitamin B12 level (if on
me�ormin), others as relevant.
Referral Referral to specialist when indicated: e.g. eye care annually, die��an
for MNT, den�st for comprehensive dental care, mental health
specialist if indicated.
- 30 -
Reference
1. Diabetes Care BADAS Guideline. h�ps://dab-bd.org/Diabetes_Care_BADAS_Guideline_
2. Distance Learning Program. Acute Complica�ons of Diabetes Mellitus. Diabetes Mellitus 2018;
5:73-87.
2022;45(1):90-92.
4. Garber AJ, Handelsman Y, Grunberger G, Einhorn D, Abrahamson MJ, Barzilay JI, et al.
Consensus Statement By The American Associa�on Of Clinical Endocrinologists And
American College Of Endocrinology On The Comprehensive Type 2 Diabetes Management
Algorithm - 2020 Execu�ve Summary. Endocr Pract. 2020;26(1):107-139. doi: 10.4158/CS-
2019-0472.
5. Interna�onal Diabetes Federa�on Guideline Development Group. Global guideline for type
2 diabetes. Diabetes Res Clin Pract. 2014;104(1):1-52.
- 31 -
Chapter-4
Acute Complications
of
Diabetes Mellitus
- 32 -
CHAPTER-4
Acute Complications of Diabetes Mellitus
Executive summary
Hypoglycemia is defined biochemically with blood glucose level below 3.9 mmol/L (70
mg/dL). In level 1 hypoglycemia blood glucose is between <3.9 and 3.0 mmol/L; in level 2,
<3.0 mmol/L, and in level 3 there is altered mental and/or physical status requiring
assistance.
Hypoglycemia should be promptly treated with oral carbohydrate in level 1 and level 2
hypoglycemia, and by parenteral glucose in level 3.
Hyperglycemic acute complica�ons demand prompt diagnosis, urgent hospitaliza�on and
management with I/V fluids, insulin etc. frequent clinical and lab monitoring.
Spectrum of acute complica�ons vary from hypoglycemia at one end to hyperglycemic

complica�ons at the other, which include diabe�c ketoacidosis, hyperosmolar hyperglycemic
state, and also lac�c acidosis.
4.1 Hypoglycemia
It is defined biochemically with blood glucose level below 3.9 mmol/L (70 mg/dL) with clinical
features of autonomic over ac�vity and neuroglycopenia.
Some people with DM, especially those with persistent high blood glucose, may develop clinical
features (par�cularly autonomic) of hypoglycemia at a higher blood glucose level.
Hypoglycemia is more common in T1DM than in T2DM.
4.1.1 Levels of hypoglycemia1

Level 1: blood glucose <3.9-3.0 mmol/L
Level 2: blood glucose <3.0 mmol/L
Level 3: a severe event characterized by altered mental and/or physical status requiring
assistance
- 33 -
4.1.2 Causes of hypoglycemia
Taking excess dose of insulin
Excess intake of an�diabe�c medica�ons, specially insulin secretagogues
Delay, omission or undue reduc�on of a meal
Unusual exercise
Severe renal or hepa�c impairment
Over intake of alcohol
4.1.3 Consequences of hypoglycemia2

Recurrent hypoglycemia may cause behavioral change and cogni�ve impairment
Increased incidence of life-threatening cardiovascular events due to severe hypoglycemia
4.1.4 Hypoglycemia unawareness and nocturnal hypoglycemia

Occurs in individuals with long standing T1DM, autonomic neuropathy, medica�ons (like non-
selec�ve beta-blockers), or very �ght glycemic control. Frequent blood glucose should be
monitored to prevent hypoglycemia.
Nocturnal hypoglycemia occurs any �me during night, usually between 2 and 4 am.
Table 4.1 Clinical features of hypoglycemia1
Level Types of feature Symptoms

Level-1 Autonomic Palpita�on, tremor, swea�ng,
hunger
Level-2 Neuroglycopenic Irritability, headache, visual
disturbance
Level-3 Neuroglycopenic Drowsiness, confusion, behavioral
abnormality, convulsion, coma
- 34 -
4.1.5 Treatment of hypoglycemia1,2
Level 1 and 2 hypoglycemia
Treated by the person him/herself or by a family member.
It is usually relieved by 15 gm glucose or equivalent food, e.g. a glass of so� drink or fruit
juice or snacks or meal (if it is due). These measures are usually adequate to raise blood
glucose to reasonably safe limit (5.5 mmol/L).
The food/drink is repeated every 15 minutes, and blood glucose should be checked every
15 minutes un�l the person is stable.
Modifica�on in ongoing treatment should be considered. Not to omit insulin/OAD
altogether; dose may be reduced according to the condi�on.
Glucagon 1 mg intramuscularly or subcutaneously can be given in those at increased risk
of level 2 hypoglycemia if it is available.
Level 3 hypoglycemia
100 ml of 25% dextrose is given intravenously under medical supervision.
If hypoglycemia is due to longer ac�ng an�diabe�c medica�ons then 10% dextrose infusion
should be started and may need to be con�nued for some �me to prevent recurrent
hypoglycemia.
Ongoing ac�vity of the an�diabe�c medica�on may lead to recurrence of hypoglycemia.
Hence, food inges�on is to be ensured a�er ini�al recovery.
If recovery does not occur, addressing addi�onal causes, modifica�on in treatment and
keeping the person under supervision in hospital may be required.
Glucagon 1 mg intramuscularly or subcutaneously can be given if it is available.
Hospitalization criteria
Level 3 hypoglycemia
Recurrent hypoglycemia
Hypoglycemia in people on long ac�ng an�diabe�c agents
- 35 -
Nocturnal hypoglycemia
Reduc�on of evening dose of insulin
Changing �me of evening insulin dose with dinner �me
Taking bed �me snacks may be considered
These adjustments are made in conjunc�on with blood glucose monitoring
4.1.6 Prevention of ‘hypo’

Frequent monitoring of blood glucose
Proper meal �ming and amount
Avoid unaccustomed exercise
Se�ng higher target for some people, e.g. older people, children, hypoglycemia
unawareness
4.2 Diabetic ketoacidosis (DKA)

Diabe�c ketoacidosis (DKA) is a medical emergency in persons with diabetes. It is commonly
found in T1DM but it also occurs in other types of diabetes during stressful situa�ons. It results
from lack of insulin and an increase in counter-regulatory hormones that lead to hyperglycemia
and subsequent lipolysis.
4.2.1 Precipitating factors

Intercurrent Infec�on
Discon�nua�on of insulin therapy
Inadequate insulin therapy
Pancrea��s, myocardial infarc�on, cerebrovascular accident, pulmonary embolism
Stressful condi�ons like trauma, pregnancy
New-onset T1DM
4.2.2 Clinical features

Develops rapidly (hours to days).
Symptoms of uncontrolled diabetes precedes.
- 36 -
Dehydra�on is the most obvious clinical feature with dry skin and tongue, low BP, rapid
weak pulse.
Acido�c breathing is characteris�c; there may be acetone smell in breath.
Weakness, vomi�ng, impairment of level of consciousness, acute abdomen.
4.3 Hyperosmolar hyperglycemic state (HHS)

HHS is a combina�on of severe degree of hyperglycemia, dehydra�on and hyperosmolality
without significant ketonuria, usually seen as complica�on of elderly T2DM persons. Here,
residual insulin reserve prevents ketosis.
4.3.1 Precipitating factors

Similar as DKA; also there may be:
Compromised fluid intake
Drugs e.g. glucocor�coids, diure�cs etc.
4.3.2 Clinical features

Develops slowly (days to weeks)
Symptoms of uncontrolled diabetes precede
Dehydra�on is profound
Impaired consciousness
Table 4.2 Diagnos�c criteria for DKA and HHS3

DKA HHS
Mild Moderate Severe
BG >13.8 mmol/L >13.8 mmol/L >13.8 mmol/L >33.3 mmol/L
Arterial PH 7.25-7.30 7.00-<7.24 <7.00 >7.30
S. bicarbonate mEq/L 15-18 10-<15 <10 >18
Urine ketone Posi�ve Posi�ve Posi�ve Small
Effec�ve serum Variable Variable Variable >320 mOsm/kg
osmolality
Anion gap >10 >12 >12 Variable
Mental status Alert Alert/drowsy Stupor/coma Stupor/coma
- 37 -
NB: Effec�ve serum osmolality: 2[Measured Na + (mEq/L)] + Glucose (mmol/L). Anion Gap: Na+
- [Cl- + HCO3- (mEq/L)].
4.3.3 Protocol for management of adult persons with DKA or HHS
Initial evaluation
Immediate hospitaliza�on
Check blood glucose/capillary glucose, serum/urine ketones: to confirm hyperglycemia and
ketonemia/ketonuria
Test for blood pH, electrolytes, urea, crea�nine, CBC
Start IV fluid as per protocol
Fluid infusion – start 0.9% NaCl @ 1.0 L/hr
Severe hypovolemia Mild dehydra�on Cardiogenic shock
0.9% NaCl @ 1.0 L/hr Measure corrected serum Na+ Specific measures
Na+ >155 mmol/L Na+ <155 mmol/L
0.45% NaCl 250-500 ml/hr 0.9% NaCl 250-500 ml/hr
When plasma glucose is

<11.1 mmol/L (DKA) or
<16.7 mmol/L (HHS)
10% dextrose
@ 125 ml/hr
NB: Corrected Na+ for hyperglycemia = Measured Na+ + [1.6 (glucose in mg/dL - 100)/100].
Figure 4.1 Fluid infusion protocol (DKA, HHS)3,4
- 38 -
Regular insulin IV
0.1 U/kg b-wt 0.14 U/kg b-wt/hr

IV bolus IV infusion
0.1 U/kg b-wt/hr

IV infusion
If plasma glucose does not fall by at least 10%

in first hour, give 0.14 U/kg IV bolus,
then con�nue as previous
DKA: When plasma glucose reaches HHS: When plasma glucose reaches
11.1 mmol/L, reduce infusion rate to 16.7 mmol/L, reduce infusion rate to
0.02-0.05 U/kg/hr. Target plasma 0.02-0.05 U/kg/hr. Target plasma
glucose is 8.4-11.1 mmol/L un�l glucose is 11.1-16.7 mmol/L un�l
resolu�on of DKA. pa�ent is mentally alert.
Figure 4.2 Insulin protocol (DKA, HHS)3,5
Measure serum K+
K+ <3.5 mmol/L K+ 3.5-5.5 mmol/L K+ >5.5 mmol/L
20-40 mmol KCl per liter 20-30 mmol KCl per liter Don’t administer KCl
of infusion fluid; of infusion fluid
may require more
rapid (hourly) infusion
Maintain serum K+ at 4-5 mmol/L. Observe renal func�on & urine output.
Figure 4.3 Potassium infusion (DKA, HHS)3,4
- 39 -
Measure blood pH
pH ≥6.9 pH <6.9
No Sodibicarb infusion 100 mmol Sodibicarb in

400 ml normal saline with
20 mmol KCL, infused over 2 hours.
Repeat every 2 hours un�l pH ≥7.
Figure 4.4 Bicarbonate infusion (DKA)3
4.3.4 Other evaluations

Blood glucose should be checked hourly ini�ally.
Blood pH, electrolytes, urea, crea�nine should be rechecked frequently as required.
A�er resolu�on of DKA/HHS and person is able to eat, SC insulin should be ini�ated. SC
insulin should be started at least 1-2 hour before stopping intravenous insulin.
During transi�on to SC insulin, mul�ply last 6 hours’ insulin dose by 4 to get 24 hours’ dose
(TDD); from this ini�ate split-mixed or basal-bolus insulin regimen.
Precipita�ng cause should be addressed.
4.3.5 Criteria for improvement of DKA/HHS3

1. No dehydra�on
2. No vomi�ng; able to take food
3. Person is well oriented and hemodynamically stable
4. No ketone in urine and anion gap normal (in DKA)
5. Effec�ve serum osmolality <315 mOsmol/kg (in HHS)
4.3.6 Complications of DKA/HHS2

Cerebral oedema
Circulatory failure
Thromboembolism
DIC
- 40 -
References
2022;45(1):S90-S92.
2. Distance Learning Program. Acute Complica�ons of Diabetes Mellitus. Diabetes Mellitus
2018; 5:89-98.
3. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult pa�ents with
diabetes. Diabetes Care 2009;32(7):1335-1343.
4. Pearson ER, McCrimmon RJ. Diabetes Emergencies. In: Ralston SH, Penman ID, Strachan
MWJ, Hobson RP, editors. Davidson’s Principles and Prac�ce of Medicine. 23 rd ed. Elsevier
2018;735-739.
5. Bangladesh Endocrine Society, Insulin Guideline Taskforce. Insulin guideline 2018. Available
from h�p://bes-org.net/wp-content/uploads/ 2019/03/Insulin%20Guidleline.pdf.
- 41 -
Chapter-5
Chronic Complications
of
Diabetes:
Prevention and Management
- 42 -
CHAPTER-5
Chronic Complication of Diabetes: Prevention and Management
Executive summary
Every person with diabetes should be screened periodically for chronic complica�ons.
Control of blood glucose, blood pressure and blood lipids along with other factors, form
the cornerstone of preven�on and control of diabe�c complica�ons.
Serum crea�nine, eGFR and urine albumin excre�on should be used for screening diabe�c
nephropathy.
Ophthalmoscopy of dilated eyes should be performed yearly to screen for re�nopathy,
with color fundus photography if needed.
Every person with diabetes should receive preven�ve foot care advices.
Chronic complica�ons of diabetes encompass a wide spectrum of microvascular (nephropathy,

re�nopathy and neuropathy) and macrovascular (coronary artery disease, cerebrovascular
disease and peripheral vascular disease) disorders. More than 50% people with diabetes have
one or more complica�ons at the �me of presenta�on, and all are treatable and preventable.
A study in 2019 found that among macrovascular complica�ons, the prevalence of coronary
artery disease was 30.5%, 10.1% for stroke and 12.0% for diabe�c foot. Among microvascular
complica�ons, prevalence of nephropathy was 34.2%, re�nopathy was 25.1% and neuropathy
was 5.8% in people with diabetes.1
5.1 Diabetic nephropathy

It is a specific form of microangiopathy of the kidney which is characterized by:
Persistent albuminuria
Progressive renal insufficiency (declining eGFR) with or without hypertension 2
5.1.1 Albuminuria
Albumin-to-crea�nine ra�o (ACR) is the preferred method to detect elevated protein in
urine. The recommended method to evaluate albuminuria is to measure urinary ACR in a
spot urine sample (preferably morning fas�ng sample before exercise).
ACR is calculated by dividing albumin concentra�on in milligrams by crea�nine
concentra�on in grams.
- 43 -
Normal: ACR <30 mg/g, normal to mildly increased albuminuria.
Microalbuminuria: ACR 30-<300 mg/g, moderately increased albuminuria.
Macroalbuminuria: ACR >300 mg/g, severely increased albuminuria.2
Table 5.1 Stages of CKD by eGFR3
Stages eGFR (ml/minute/1.73m2) Description

1 ≥90 Renal damage + normal or raised GFR
2 60 to 89 Renal damage + mildly decreased GFR
3 30 to 59 Moderately decreased GFR
4 15 to 29 Severely decreased GFR
5 <15 or on dialysis Kidney failure
Markers of renal damage (one or more)4

Albuminuria (AER ≥30 mg/24 hours; ACR ≥30 mg/g [≥3 mg/mmol])
Urine sediment abnormali�es
Electrolyte and other abnormali�es due to tubular disorders
Abnormali�es detected by histology
Structural abnormali�es detected by imaging
History of kidney transplanta�on
5.1.2 Screening and follow up2

Full clinical check-up during each visit, especially anemia, blood pressure, pedal edema etc.
AER (albumin excre�on rate) and eGFR or CCr es�ma�on. Two of three samples of AER
should be abnormal in 3-6 months.
Blood urea, crea�nine, total protein, albumin, electrolytes, uric acid, calcium and
phosphate es�ma�on.
Serum crea�nine and eGFR should be assessed at least annually.
Monitoring of other urinary complica�ons e.g. UTI (including asymptoma�c), bladder
dysfunc�on (autonomic bladder) etc.
Monitoring by sonography – kidney size, progressive increase in echogenicity of cortex.
Renal biopsy may be required in nephropathy in absence of re�nopathy, heavy proteinuria,
rapid unexplained deteriora�on of renal func�on etc.
- 44 -
5.1.3 Treatment2
Good glycemic control reduces the incidence of diabe�c nephropathy and delays its
progression, evidence suggests that SGLT2 inhibitors and GLP1-RA are beneficial, if not
contraindicated.
Control of hypertension is very important because uncontrolled hypertension causes rapid
progression of diabe�c nephropathy. Target of BP is <130/80 mm of Hg.
ACE inhibitors and ARBs are preferred drugs to reduce or revert early nephropathy. But
these two drugs must not be combined. Check electrolytes and crea�nine 2 weeks a�er
star�ng and stop if >30% increase of baseline serum crea�nine or hyperkalemia.
Protein intake up to 0.8 gm/kg/day of body weight is allowed.
Correct high phosphate and uric acid. Restrict high uric acid and phosphate-containing
foods if necessary.
Fluid and electrolyte balance should be maintained.
Iron supplementa�on o�en fails to correct anemia in renal failure. Iron along with
erythropoie�n provides the op�mum response.
Renal replacement therapy (dialysis and renal transplanta�on) is done when indicated.
Kidney func�on tests:

• At diagnosis & then once a year in T2DM
• Yearly at or a�er 5 years (or earlier) of diagnosis in T1DM
• Urinary albumin/microalbumin
• Serum crea�nine
Evidence of nephropathy
(with classifica�on)
• Establish & maintain HbA1c <7%

• Treat hypertension & maintain BP <130/80 mmHg
• Look for other microangiopathies/complica�ons
Referral to nephrologist:
• eGFR <30 mL/min/1.73m2
• Uncertainty about the e�ology of kidney disease
• Difficult management issues
• Rapidly progressing kidney disease
Figure 5.1 Decision making path: nephropathy2
- 45 -
5.2 Diabetic retinopathy
Diabe�c re�nopathy is the most frequent cause of new cases of blindness in our country.
Glaucoma, cataract, and other disorder of the eye occur earlier in persons with diabe�c.
5.2.1 Screening and follow-up

In T1DM
An ini�al dilated, comprehensive eye examina�on by an ophthalmologist or optometrist within
5 years of diagnosis and then annually. If re�nopathy is progressing or sight-threatening, then
an examina�on should be done frequently.
In T2DM
An ini�al dilated, comprehensive eye examina�on by an ophthalmologist or optometrist at the
�me of the diabetes diagnosis and then annually. If re�nopathy is progressing or sight-
threatening, then examina�ons should be done frequently.
In women with T1DM or T2DM

If planning pregnancy, should have screening for re�nopathy before pregnancy. During
pregnancy, a repeat eye examina�on should be done.
Table 5.2 Classifica�on of diabe�c re�nopathy2

Stage Characteristic lesions
Early non-prolifera�ve diabe�c Microaneurysm, dot and blot hemorrhage, hard
re�nopathy (NPDR) exudate.
Moderate to severe non-prolifera�ve Co�on wool spots/so� exudate, venous beads and
diabe�c re�nopathy (NPDR) loops, intrare�nal microvascular abnormali�es
(IRMA)
Prolifera�ve diabe�c re�nopathy Neovasculariza�on of disc (NVD), Neovasculariza�on
(PDR) elsewhere (NVE), vitreous hemorrhage, trac�onal
re�nal detachment
Maculopathy Edema, exudate or hemorrhage in and around
macula
- 46 -
Eye Examina�on:
• At diagnosis & then once a year in T2DM
• Yearly at or a�er 5 years (or earlier) of diagnosis in T1DM
• Ophthalmoscopy of dilated eye

• Fundus photography when needed
Evidence of ophthalmopathy
(with classifica�on)
• Establish & maintain HbA1c <7%

• Treat hypertension & maintain BP <130/80 mmHg
• Look for other microangiopathies/complica�ons
Referral to ophthalmologist:
If the re�nopathy is beyond early NPDR
Figure 5.2 Decision making path: re�nopathy2
5.3 Diabetic neuropathy

5.3.1 Types
1. Soma�c – sensory, motor, cranial (focal neuropathy)
2. Autonomic – gastroparesis, hypoglycemia unawareness, postural hypotension, erec�le
dysfunc�on etc.
5.3.2 Screening
Star�ng at diagnosis of T2DM, then annually.
5 years a�er the diagnosis of T1DM, then annually.
Tes�ng sensory neuropathy by 10-g monofilament.
Assessment of either temperature or pinprick sensa�on (small fiber func�on) and vibra�on
sensa�on using a 128-Hz tuning fork (for large-fiber func�on).
Symptoms and signs of cranial and autonomic neuropathy should also be assessed.
- 47 -
5.3.3 Treatment2
Treatment of painful diabe�c peripheral neuropathy
o Metabolic control: op�mum glycemic control.
o For burning pain: an�depressants e.g. duloxe�ne, tricyclic an�depressants etc. or
an�convulsants e.g. gabapen�n, pregabalin, or topical capsaicin etc. are used.
o For lancina�ng pain: an�convulsants e.g. carbamazepine, phenytoin or valproate are
used.
o For painful cramps: quinine sulfate. Aldose reductase inhibitors may be used.
o Other contribu�ng factors e.g. alcohol, cord lesions, vitamin deficiency, renal failure
etc. should be addressed.
Treatment of autonomic neuropathy
o Metabolic control: good metabolic control may halt its progression
o For gastroparesis: erythromycin, metoclopramide, domperidone
o For diarrhoea: an�bio�cs, loperamide
o For impotence: PDE5 inhibitors
o For neurogenic bladder: intermi�ent catheteriza�on, surgery, drug (rarely)
o For orthosta�c hypotension: midodrine, mineralocor�coids, elas�c stockings, fluid and
salt intake, posi�onal adjustments etc.
o Suppor�ve measures e.g. physiotherapy
5.4 Diabetic Foot

Most common cause of non-trauma�c amputa�on is diabe�c foot, which is preventable
and treatable.
Comprehensive foot evalua�on should be done ini�ally and at least annually to iden�fy risk
factors for ulcers and amputa�ons.
Individuals with sensory loss or prior ulcera�on or amputa�on should have their feet
examined at every visit.
5.4.1 History
Prior history of ulcera�on, amputa�on, Charcot foot, angioplasty or vascular surgery,
cigare�e smoking, re�nopathy.
- 48 -
Current symptoms of neuropathy (pain, burning, numbness) and vascular disease (fa�gue,
claudica�on).
5.4.2 Examination
Inspec�on of the skin
Assessment of foot deformi�es
Neurological assessment: 10-g monofilament tes�ng with at least one other assessment:
pinprick, temperature, vibra�on
Vascular assessment: pulses in the legs and feet. With symptoms of claudica�on or
decreased or absent pedal pulses: ankle-brachial index, further vascular assessment as
appropriate e.g. doppler study
Table 5.3 Risk categories of diabe�c foot:5
Normal plantar Loss of protec�ve LOPS with either History of

sensa�on sensa�on (LOPS) high pressure or poor ulcera�on,
circula�on or structural amputa�on or
foot deformi�es or neuropathic
onychomycosis fracture
LOW RISK MODERATE RISK HIGH RISK VERY HIGH RISK
5.4.3 Management
A mul�disciplinary approach is recommended.
Provide general preven�ve foot self-care educa�on to all individuals with diabetes.
Specialized therapeu�c footwear is recommended for high-risk persons with diabetes
including those with severe neuropathy, foot deformi�es, or history of amputa�on.
Do’s and don’ts for people at risk of diabetic foot

Do’s
Check feet daily for cuts, blisters, colour changes, swelling, ingrown toe nails. Use a mirror
or take someone’s help if required
Always protect feet with appropriate footwear
Before wearing shoes check inside for nails, stones or any other sharp object
- 49 -
Wear socks with shoes; use co�on socks
Wash socks daily; make sure they have no holes
Buy new shoes at the end of the day
A�er washing, dry feet carefully especially between toes
Cut nails straight across and file the sharp edges
Annual foot examina�on by healthcare professional
Don’ts
Avoid barefoot walking
Avoid �ght or torn shoes with rough and uneven edges
Avoid shoes with narrow toe box, high heels or footwear that have no back supports
Don’t use socks with �ght top or rough sim
Don’t use hot water to wash feet
Don’t let the feet dry and cracked
Don’t use corn medicine or blades to remove it by self
5.4.4 Referral criteria to foot care specialists

History of prior lower-extremity complica�ons
Loss of protec�ve sensa�on
Structural abnormali�es of foot
Peripheral arterial disease
Presence of ulcer, gangrene or infec�on
5.5 Cardiovascular diseases

More than 70% people with DM die due to cardiovascular causes.
5.5.1 Screening
Screening for coronary artery disease should be done in symptoma�c persons and people with
risk for cardiovascular disease.
- 50 -
5.5.2 Treatment
ACE inhibitor or angiotensin receptor blocker
SGLT2 inhibitors and GLP1-RA
Sta�ns
Aspirin and/or clopidogrel
Selec�ve beta-blockers should be con�nued for at least 2 years a�er the event
5.5.3 Hypertension
Hypertension is a common comorbidity of DM.
Blood pressure should be measured in every follow-up.
Target is <130/80 mmHg for non-pregnant adult.
If blood pressure is >130/80 mmHg but <140/90mmHg, then lifestyle modifica�on.
If blood pressure is >140/90 mmHg, recheck a�er 1week. If s�ll high then lifestyle
modifica�on and monotherapy.
If blood pressure is >160/100 mmHg, start dual an�hypertensive.
The choice can be ACE inhibitor or ARB, Calcium channel blocker and diure�cs.
Selec�ve beta blocker or alpha blocker can be used in special situa�on.
5.5.4 Dyslipidemia
Diabe�c dyslipidemia is very common. Screening and Monitoring of lipid profile should be done
at the �me of diabetes diagnosis, at an ini�al medical evalua�on, yearly and more frequently
if indicated.
Table 5.4 Targets of blood lipids in person with DM6

Lipid Target level
LDL cholesterol <70mg/dL
Triglyceride <150 mg/dL
HDL cholesterol >40 mg/dL (male), >50 mg/dL (female)
- 51 -
Treatment
Lifestyle modifica�on:
Maintain ideal body weight
Avoid saturated and trans fats
Increase dietary omega-3 fa�y acids, fibers, and green leafy vegetables and fresh fruits
Increased physical ac�vity
Table 5.5 Pharmacological therapy based on age, ASCVD or ASCVD risk factors6,7
Age in years ASCVD or 10-year Recommended pharmacological therapy,
ASCVD risk >20% along with lifestyle modification
<40 No None or moderate intensity sta�n may be considered based
on risk-benefit profile or presence of ASCVD risk.
<40 Yes High-intensity sta�n; if LDL cholesterol ≥70 mg/dL despite of
therapy consider combining with eze�mibe.
≥40 No Moderate-intensity sta�n or high-intensity sta�n may be
considered based on risk-benefit profile or presence of
ASCVD risk.
≥40 Yes High-intensity sta�n; if LDL cholesterol ≥70 mg/dL despite of
therapy, consider combining with eze�mibe.
NB: Intensity of sta�n therapy may need to be adjusted according to individual response to
medica�on (e.g. side effects, tolerability, LDL cholesterol levels, etc).
5.5.5 Antiplatelet agents6

Aspirin therapy (75–150 mg/day) as a secondary preven�on strategy in those with diabetes
and a history of atherosclero�c cardiovascular disease.
Persons with atherosclero�c cardiovascular disease and documented aspirin allergy,
clopidogrel (75 mg/day) should be used.
Dual an�platelet therapy is reasonable for a year a�er an acute coronary syndrome.
For primary preven�on of ASCVD, aspirin is recommended for those with diabetes and age
>50 years, having at least one major risk factor for ASCVD.
- 52 -
References
1. Afroz A, Zhang W, Wei Loh AJ, Jie Lee DX, Billah B. Macro- and micro-vascular complica�ons
and their determinants among people with type 2 diabetes in Bangladesh. Diabetes Metab
Syndr. 2019;13(5):2939-2946. doi:10.1016/ j.dsx.2019.07.046.
2. Diabetes Care BADAS Guideline. h�ps://dab-bd.org/Diabetes_ Care_ BADAS_ Guideline_
3. American Diabetes Associa�on Professional Prac�ce Commi�ee. 11. Chronic kidney
disease and risk management: Standards of Medical Care in Diabetes—2022. Diabetes Care
2022;45(Suppl. 1):S175–S184.
4. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical
Prac�ce Guideline for the Evalua�on and Management of Chronic Kidney Disease. Kidney
inter., Suppl. 2013; 3: 1–150.
5. Interna�onal Diabetes Federa�on. Clinical Prac�ce Recommenda�on on the Diabe�c Foot:
A guide for health care professionals: Interna�onal Diabetes Federa�on, 2017.
6. American Diabetes Associa�on Professional Prac�ce Commi�ee. 10. Cardiovascular
disease and risk management: Standards of Medical Care in Diabetes—2022. Diabetes Care
2022;45(Suppl. 1):S144–S174.
7. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al. 2018
AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the
management of blood cholesterol: a report of the American College of
Cardiology/American Heart Associa�on Task Force on Clinical Prac�ce Guidelines.
Circula�on. 2019;139:e1082–e1143. DOI: 10.1161/CIR.0000000000000625.
- 53 -
Chapter- 6
Special Situations
in
Diabetes Mellitus
- 54 -
CHAPTER-6
Special Situations in Diabetes Mellitus
Executive summary
All women planning for pregnancy or conceived should be screened for diabetes. Only
insulin is recommended for use in pregnancy and lacta�on period.
Insulin is the only therapy in children <10 years of age. Me�ormin can be given a�er 10
years.
In hospital admi�ed pa�ents, insulin therapy should be ini�ated in persistent
hyperglycemia >10 mmol/L, checked on two occasions. Target blood glucose is to be
maintained between 7.8 and 10 mmol/L. In cri�cal se�ng intravenous insulin infusion is
preferred.
During sick days, the person should be advised to check blood glucose at home frequently
and take plenty water and fluid.
Diabetes educa�on and counselling should be given prior to Ramadan and Hajj.
6.1 Hyperglycemia in pregnancy

Hyperglycemia in pregnancy may be due to GDM (diabetes that is first �me detected during
gesta�on who is not known to have it before) or preexis�ng prediabetes or diabetes in a
pregnant woman. Hyperglycemia in pregnancy is caused by placental hormones, namely beta
HCG, human placental lactogen, estrogen, progesterone etc. antagonizing the ac�on of
insulin.1 The incidence of GDM is rising in all South East Asian countries and the prevalence in
Bangladesh has been reported to be around 10%.2
6.1.1 Risk factors3

BMI ≥23 kg/m2
Age >25 years
First degree rela�ve with DM
History of delivery of baby >9lb or LGA or bad obstetric history
Previous history of GDM, HbA1c ≥5.7%, IGT or IFG
Physical inac�vity
HTN or therapy for HTN, HDL <35 mg/dL and or TG >250 mg/dL, PCOS, acanthosis nigricans,
history of CVD
- 55 -
6.1.2 Screening and diagnostic criteria for GDM
See Chapter 2.
6.1.3 Preconception care1

Preconcep�on HbA1c should be below 6.5%
Women receiving non-insulin an�hyperglycemic agents should shi� to insulin before
concep�on
Review of medica�on list for poten�al harmful drugs like ACEI, ARBs or sta�ns should be
done
6.1.4 Management
Medical nutrition therapy
MNT Should be started soon a�er diagnosis of GDM preferably by die��an and reviewed
in each trimester.
The aim is to achieve normoglycemia, adequate maternal weight gain, adequate fetal
growth, preven�on of ketosis.
Table 6.1 Recommended weight gain during pregnancy based on pre-pregnancy BMI3
BMI [kg/m2] Recommended wt gain [Ibs (kg)]

Singleton pregnancy
<18.5 28-40 (12.5-18.0)
18.5-24.9 25-35 (11.5-16.0)
25.0-29.9 15-25 (7.0-11.5)
≥30.0 11-20 (5-9.0)
Twin pregnancy
<18.5 No recommenda�on
18.5-24.9 37-54 (16.8-24.5)
25.0-29.9 31-50 (14.1-22.7)
≥30.0 25-42 11.4-19.1)
Table 6.2 Daily calorie alloca�on according to pre-pregnancy weight3
- 56 -
Pre-pregnancy weight During first trimester During 2nd and 3rd trimester
(BMI in kg/m2) (kcal/kg/day) (kcal/kg/day)
<18.5 35 40
18.5 to 22.9 30 35
23 to 27.4 25 30
> 27.5 30-33% calorie restric�on
Meal pattern
3 main meals and 3 snacks should be taken including 1 snack at bed �me.
Recommended overall total caloric distribution3

Carbohydrate: 33-40% with low glycemic index
Protein: ~ 20%
Fat: <40%, saturated fat <7% and transfat <1%
Simple sugars should be avoided. Food containing complex carbohydrate is recommended
High dietary fiber and whole grain containing foods should be encouraged
Non-calorie sweeteners (aspartame) may be used safely
Lean protein, oily fish and vegetable consump�on should be increased
Recommended daily requirement of iron- 30 mg, calcium- 1000 mg and folate- 0.6 mg
Physical activity1
Moderate exercise, aerobic, resistance or both are effec�ve. Dura�on of exercise can be
20-50 minutes/day, 2-7 days/week of moderate intensity.
While doing exercise excessive abdominal muscular contracture should be avoided.
- 57 -
Pharmacological management
FPG 5.1-6.0 mmol/L FPG 6.1-7.0 mmol/L FPG ≥7.0 mmol/L
and/or and/or and/or
2h PPG 6.7-7.8 mmol/L 2h PPG 7.8-11.1 mmol/L 2h PPG ≥11.1 mmol/L
Lifestyle Lifestyle Lifestyle +

modifica�on modifica�on Pharmacological
1 week 3 days
Target not Target Target not Target

achieved achieved achieved achieved
Lifestyle + Con�nue Lifestyle + Con�nue

Pharmacological Lifestyle Pharmacological Lifestyle
Figure 6.1 Diabetes management during first and third trimester3
FPG 5.1-6.0 mmol/L FPG 6.1-7.0 mmol/L FPG ≥7.0 mmol/L

and/or and/or and/or
2h PPG 6.7-7.8 mmol/L 2h PPG 7.8-11.1 mmol/L 2h PPG ≥11.1 mmol/L
Lifestyle Lifestyle Lifestyle +

modifica�on modifica�on Pharmacological
1 week 3 days
Target not Target Target not Target

achieved achieved achieved achieved
Lifestyle + Con�nue Lifestyle + Con�nue

Pharmacological Lifestyle Pharmacological Lifestyle
Figure 6.2 Diabetes management during second trimester3
- 58 -
Recommended insulins
Recombinant human short and intermediate (NPH) ac�ng insulin
Rapid ac�ng analogue aspart and lispro
Long-ac�ng analogue detemir
Required ini�al daily dose is 0.2 to 0.5 unit/kg body weight. Obese women may need higher
dose Treatment should be graded to reach the targets
Approach to start insulin

Step 1: Raised post meal blood glucose should be controlled by bolus insulin – either by
regular/short ac�ng human insulin or by short/ultra-short ac�ng analogue with meal(s) and
�trated frequently to reach the post-meal targets.
Step 2: High FPG should be controlled with intermediate ac�ng human insulin (NPH) or basal
analogue insulin in a lower dose then �trated to reach the target.3
Only bolus insulin may be needed in some cases of GDM when FPG is well controlled
Pre-mixed insulin is usually not preferred
Non-insulin an�hyperglycemic agents are not recommended
Target 1
Fas�ng blood glucose <5.3 mmol/L (95 mg/dL)
2-hour post-prandial glucose <6.7 mmol/L (120 mg/dL)
Glucose monitoring
Every woman should be offered educa�on and encouraged for self-monitoring of pre- and
post-meal glucose at home, twice or thrice a week.
HbA1c should be used as secondary measure of glycemic control, a�er blood glucose
monitoring.
Management during labor4

Hospital delivery is mandatory.
Indica�ons for C/S are the same for those with other women.
Maternal glucose should be maintained between 4.0 to 7.0 mmol/L during labor.
- 59 -
Most women who require <1.0 unit/kg/day insulin can simply be monitored without
intravenous Insulin.
If needed infusion of 5% Dextrose with short ac�ng Insulin can be maintained but Glucose-
Insulin infusion should be stopped immediately a�er delivery.
Blood glucose of newborn should be seen by heel prick within half an hour.
6.1.5 Postpartum management3

Mothers who were on low dose insulin (<0.5 unit/kg/day) can stop and monitor glucose
levels. Mothers who were on insulin >1 unit/kg/day may reduce the dose to 50% and while
those on 0.5-1 units need individualized clinical decision.
If BG is normal, re-assessment should be done annually with 75-gm 2h OGTT or HbA1c. If
prediabetes, should be put on MNT with standard protocol.
A�er delivery at least 1 fas�ng and 1 post-meal PG before discharge should be measured
in persons with GDM who were managed by MNT and FPG and PPG should be monitored
for at least 24 hours who were managed with insulin. If blood glucose remains elevated,
con�nued monitoring is warranted. If immediate post-delivery (1-3 days) BG is sugges�ve
of DM, then should be confirmed by FPG (≥7 mmol/L) or post-prandial BG (≥11.1 mmol/L).
As some case of GDM may represent preexis�ng undiagnosed type 2 diabetes and 50%
women with GDM may develop type 2 DM within 5 to 10 years. Women with GDM (not
requiring insulin a�er delivery) should be screened for diabetes 6 weeks post-partum
(linked to child immuniza�on) with 75g 2h OGTT using non-pregnant OGTT criteria.
Contracep�on advice should be given. Low dose estrogen-progesterone can be offered for
contracep�on. Progesterone only prepara�on increases risk of vascular complica�ons.
All types of insulins can be safely used in lacta�ng women. Women with pre pregnancy
diabetes who are breas�eeding should con�nue to avoid any drugs for the treatment of
diabetes.
All mothers with history of GDM should be counseled about screening for GDM during
every subsequent pregnancy.
- 60 -
6.2 Diabetes in children and adolescent
Diabetes mellitus in childhood and adolescence is most o�en T1DM, but the incidence of T2DM
is also increasing due to the rising rate of obesity among children, especially in Bangladesh.
6.2.1 Diagnosis and screening in children and adolescent

See Chapter 2.
6.2.2 Principles of management

In T1DM, insulin is the only choice. In T2DM, treatment modali�es change according to age.
Table 6.3 Target level of glucose5
Plasma glucose mmol/L

FBS/Pre-meal 5.0-7.2
Post-meal 5.0-10.0
Pre-bed 5.0-8.3
HbA1c % <7.0
Table 6.4 Drug treatment of T2DM6
Age in years Treatment option

<10 Insulin only
10-18 Insulin or me�ormin
>18 Insulin or me�ormin, or other an�diabe�c agent, e.g.
sulfoylureas, thiazolidindiione
Diabetes education1
Diabetes educa�on is very essen�al part for effec�ve management diabetes in this age
group especially insulin injec�on technique, dietary prac�ce, home monitoring of blood
glucose etc. are needed. Providing emo�onal support is also very important.
Infants and toddlers: They are totally dependent on parents and care providers for
injec�ons, food and monitoring. Need to be educated on preven�on, recogni�on and
- 61 -
management of acute complica�ons, especially hypoglycemia, because it is very common
complica�on in this age group.
School going children: To be trained on Insulin injec�ons and blood glucose monitoring,
recognizing hypoglycemic symptoms, and understanding self-management, adapt to
school programs, school meals, exercise and sports. Teacher/school authority should be
involved in this learning process and parents are advised on the gradual development of
the child's independence.
Adolescents: Independent, responsible self-management appropriate to the level of
maturity and understanding should be promoted.
Medical nutrition therapy (MNT)1

All children with diabetes should be referred to a die��an for counseling at diagnosis of
diabetes and subsequently if they have problem with their diet adjustment.
Age-specific calorie calcula�ng charts are available for measuring diet allowance.
Sports and exercise1

Children with T1DM with good blood glucose control can do all levels of exercise, including
leisure ac�vi�es, recrea�onal sports and compe��ve professional performance. Exercise is
more important for young T2DM, especially who are obese.
Children between 3-5 years of age may take part in free play, walking, running etc.
Children between 6-9 years of age may start learning to play team sports such as football,
cricket etc.
Children above 10 years of age and adolescents may be able to take part in all complex
sports, like basketball, football, tennis, hockey etc.
6.2.3 Screening and treatment of complications and comorbidities6
Hypertension
Blood pressure (BP) should be monitored at diagnosis and at every follow-up visit.
Target BP (mmHg) < 90th percen�le for age, sex, and height and if age >13 years old <
130/80.
- 62 -
Lifestyle modifica�on for elevated BP (90-95th percen�le for age, sex, and height or if age
> 13 years 120-129/<80).
Lifestyle modifica�on and ACEI or ARB for hypertension (>95th percen�le for age, sex and
height or if age >13 years old >130/80).
Dyslipidemia
Lipid profile should be performed in children soon a�er diagnosis of DM (preferably a�er
control of diabetes or age >2 year)).
If lipids are abnormal, annual monitoring is recommended.
If LDL cholesterol values are within the accepted risk levels (<100 mg/dL), a lipid profile
should be repeated every 3-5 years.
Ini�al therapy includes blood glucose control and MNT.
A�er the age of 10 years, sta�n is recommended in those who do not reach target (who
have LDL cholesterol >160 mg/dL or >130 mg/dL with a cardiovascular risk factor) with
lifestyle changes.
The goal of therapy is LDL cholesterol value <100 mg/dL.
Nephropathy
Albumin crea�nine ra�o (ACR) should be measured at puberty or age >10 years old
whichever is earlier and diabetes dura�on of > 5 years.
If normal screen annually, if abnormal it should be confirmed by repea�ng the test from 2
out of 3 sample in 6 months.
Retinopathy
Dilated fundoscopy should be performed to screen for re�nopathy at puberty or at age >11
years old whichever is earlier and diabetes dura�on of 3-5 years. If normal, every 2 years.
Neuropathy
Foot examina�on with foot pulse, pinprick, vibra�on test, ankle jerk and 10-gm monofilament
sensa�on test (if possible) should be performed at puberty or at 11 years of age whichever is
earlier and diabetes dura�on of 5 years. If normal, annually.
- 63 -
Other autoimmune disease
For those with type 1 diabetes advise for thyroid func�on test and IgA of tTG for celiac disease
if possible soon a�er diagnosis.
6.3 Diabetes in elderly

Prevalence of diabetes is high in older popula�on. One fourth of older adult age >65-years
old are diabe�c and one half of older adult have prediabetes. Older adults with diabetes
have high incidence of premature death, disability, muscle loss, and associated with other
coexistent illness like hypertension, coronary heart disease and stroke, than those without
diabetes.
Assessment of medical and psychological factors, self-management abili�es, social factors
in older adults are necessary for be�er diabetes management, and to determine the target
and therapeu�c op�ons.
Screening for early detec�on of mild cogni�ve impairment or demen�a should be
performed for adults 65 years of age or older at the ini�al visit, annually and as appropriate.
6.3.1 Treatment goals7

Older adults who are otherwise healthy with few coexis�ng chronic illnesses and intact
cogni�ve func�on and func�onal status should have lower glycemic goals (such as HbA1c
less than 7.5%, FPG <7.2 mmol/L, PPG <10.0 mmol/L).
Those with mul�ple coexis�ng chronic illnesses, cogni�ve impairment or func�onal
dependence should have less stringent glycemic goals (such as HbA1c 8.0-8.5%, FPG <10
mmol/L, PPG <11.1 mmol/L).
Screening for diabetes complica�ons should be individualized in older adults, par�cularly
complica�ons that would lead to func�onal impairment.
Treatment of hypertension to individualized target levels is indicated in most older adults.
Treatment of other cardiovascular risk factors should be individualized in older adults
considering the �me frame of benefit.
Lipid lowering therapy and aspirin therapy may benefit those with life expectancies at least
equal to the �me frame of primary preven�on or secondary interven�on trials.
- 64 -
6.3.2 Management7
Lifestyle management
Op�mal nutri�on and protein intake is recommended for older adults; regular exercise,
including aerobic ac�vity, weight-bearing exercise, and/or resistance training should be
encouraged in all older adults who can safely perform such ac�vi�es.
Modest weight loss (e.g. 5-7%) should be considered for obese older adult with diabetes.
Pharmacologic therapy
As increased risk of hypoglycemia in older diabe�c people, medica�on classes with low risk
of hypoglycemia are preferred.
Avoid overtreatment of diabetes.
Simplifica�on of complex regimens is recommended to reduce the risk of hypoglycemia
and polypharmacy.
Consider costs of care when developing treatment plans to reduce risk of cost-related
nonadherence.
Oral drug Me�ormin is the first line therapy, but should be used cau�ously.
Those who are on short acing (prandial) insulin, with prandial insulin >10 units/dose,
consider 50% reduc�on of dose and addi�on of non-insulin agent. If dose of prandial insulin
<10 units/dose discon�nue prandial insulin and no-insulin agent.
SGLT2 inhibitors, GLP1-RA can be used if tolerated and not contraindicated.
6.4 Management of hyperglycemia in hospitalized patients1

Hyperglycemia in hospitalized pa�ents is defined as blood glucose levels >7.8 mmol/L.
HbA1c should be measured in all pa�ents with diabetes or hyperglycemia admi�ed to the
hospital if the test has not been performed in the previous 3 months.
An admission HbA1c value 6.5% or more suggests that the onset of diabetes preceded
hospitaliza�on.
- 65 -
6.4.1 Management
Insulin therapy should be ini�ated for treatment of persistent hyperglycemia at a threshold
>10.0 mmol/L (checked on two occasions).
Once insulin therapy is started, a target glucose range of 7.8-10.0 mmol/L is recommended
for the majority of cri�cally ill and non-cri�cally ill patients.1
Table 6.5 Insulin therapy in cri�cal and noncri�cal se�ng 1
Critical setting Non-critical setting

Con�nuous IV Insulin infusion is Basal or basal plus/NPH or NPH plus short ac�ng
most preferred insulin for those who has poor oral intake
More frequent monitoring and Basal-bolus/split mixed + correc�onal for those
adjustment needed who have good intake
Insulin therapy1
Insulin therapy is preferred for treatment of hyperglycemia in all hospitalized individuals.
In noncri�cal se�ng, scheduled insulin regimen is recommended.
Use of sliding scale insulin regimen is strongly discouraged.
Pre-mixed insulin is not preferred in hospitalized pa�ents.
If oral intake is poor, a safer procedure is to administer prandial insulin immediately a�er
the person eats.
Glucose monitoring in hospital1

Those who are on oral feeding: bedside glucose monitoring before meals and 2 hours
a�er meals.
Those who are on NG tube/NPO: bedside glucose monitoring every 4-6 hours.
In cri�cal se�ng, who are on IV insulin: more frequent monitoring from every 30 minutes
to 2 hours may be needed.
- 66 -
6.4.2 Perioperative management
Pre-opera�ve assessment must be done in close consulta�on with the physician, surgeon
and anesthe�st.
Me�ormin should be stopped 24 hours prior to or on the day of surgery.
SGLT2 inhibitors must be discon�nued 3-4 days before surgery.
Withhold any other oral glucose lowering agents in the morning of surgery or procedure
and give half of NPH dose or 75-80% doses of long ac�ng analogue if scheduled in morning.
The target blood glucose in periopera�ve period is 7.7-10.0 mmol/L.9
In all major surgeries glucose-insulin infusion should be started. The unit of insulin to be
added to 5 or 10% dextrose or dextrose saline needs to be individualized and adjusted as
per the results of the glucometer readings.
Blood glucose should be monitored 2 to 4 hourly. Glucose-insulin-potassium infusion may
be considered according to situa�ons. Best op�on I/V insulin syringe pump which can be
prac�ced in long surgical procedure.
During minor surgery glucose-insulin infusion may some�mes be required in uncontrolled
diabetes, but not in stable state.
Table 6.6 Insulin dose adjustment prior and during surgery10

Diet Glargine/ detemir NPH/pre-mixed Regular/rapid
acting
AM PM AM PM AM PM
Day before Normal diet Usual 80% of 80% of 80% of Usual Usual
surgery un�l midnight dose usual usual usual dose dose
(Insulin) dose dose dose
Only liquid 12- Usual 80% of 80% of 80% of Hold Hold
24 hrs prior dose usual usual usual
surgery dose dose dose
Day of NPO 80% of usual dose 50% of usual dose Hold
surgery if the person uses Hold if BG<6.6
(Insulin) twice daily basal mmol/L
insulin
- 67 -
Post-operative care1
The glucose-insulin administra�on is con�nued (where required) �ll the person is able to
take oral food.
At this �me, if the blood glucose is not under fair control, rapid ac�ng insulin can be given
in small doses (as correc�onal dose) subcutaneously.
Once the person is back on his rou�ne diet and is stable, he or she can be managed with
the prior regimen to surgery.
6.4.3 Glucocorticoid therapy in hospitalized patients1

The prevalence of Glucocor�coid use in hospitalized pa�ents can be as high as 10%.
Those on morning steroid regimens have dispropor�onate hyperglycemia during the day,
but frequently reach normal blood glucose overnight.
In individuals with once or twice daily steroids, administra�on of NPH insulin is a standard
approach. As NPH ac�on peaks at 4-6 hours a�er administra�on, it is best to give
concomitantly with steroid.
For long ac�ng glucocor�coids like Dexamethasone and mul�dose or con�nuous steroid
use, long ac�ng insulin required to control fas�ng blood glucose.
Insulin dose should be adjusted with an�cipated change in steroid dosing.
6.4.4 Glucose management in enteral and parenteral feeing11

Enteral feeding
Enteral nutri�on is started via nasogastric tube, or less frequently, percutaneous gastric tube.
Diabe�c specific formulas contain carbohydrates with monounsaturated fa�y acids (up to 35
% of total calories), dietary fiber (10-15 g/L), and fructose. Low dose basal insulin in
combina�on with supplemental regular insulin was shown to be effec�ve in providing glycemic
control in majority of pa�ents receiving enteral feedings.
Parenteral feeding
Both subcutaneous and intravenous insulin have been shown to be effec�ve in managing
hyperglycemia in pa�ents with TPN. In cri�cally ill or hemodynamically compromised pa�ents,
treatment with intravenous con�nuous insulin infusion is preferred. Adding insulin to TPN
mixture is clinically safe and effec�ve in controlling hyperglycemia during TPN. Adding insulin
- 68 -
at the ra�o of 1 unit of insulin per 11 g of dextrose in persons with diabetes receiving TPN
containing 150-300 g of carbohydrates per day is an effec�ve ini�al step to prevent and reduce
hyperglycemia.
6.5 Sick day management12

Period of illnesses e.g. fever, vomi�ng or diarrhoea, o�en cause hyperglycemia and ketosis,
and some�mes hypoglycemia. To prevent these, certain management principles are followed:
The person needs to test his/her blood for glucose 4 hourly at home and if possible test
urine Ketones. The blood glucose measurements should be wri�en down in a diary.
The aim or target to maintain between 6-10 mmol/L.
Be aware of signs of hypoglycemia. Manage Hypoglycemia at home promptly and test more
frequently.
Fluid balance needs to be maintained; during illness sufficient intake is necessary. If the
blood glucose is low, sweetened fluids, e.g. fruit juice can be given. If blood glucose is
elevated, low calorie so� drinks, soup or broth may be given. Drink 120-180 ml of water or
calorie free fluid each half hourly when awake. Try to eat normal meal schedule.
Contact by telemedicine if required.
The OADs should never be stopped altogether; dose may need to be reduced. If there is
acute illness, specially in vom�ng and diarrhoea, stop Me�ormin temporarily. Stop SGLT2
inhibitor to avoid ketosis and dehydra�on. DPP4 inhibitors can be con�nued. SU should be
used cau�ously, dose may be readjusted.
Do not stop insulin. Intermediate or basal insulin should be con�nued; the dose may need
to be readjusted. If blood glucose remains above 10 mmol/L, increase insulin by 2 units. If
decreased below 6 mmol/L, reduce insulin dose by 2 units. Shorter ac�ng insulin should be
adjusted according to blood glucose values and food intake. If necessary, short/rapid ac�ng
insulin can be given a�er meal, seeing the amount of intake or vomi�ng.
Some�mes the OADs may need to be replaced by shorter ac�ng ones or insulin. If OAD
need to be discon�nued, the alterna�ve is insulin.
These principles are to be followed un�l the blood glucose is <12 mmol/L and ketone
diminishes or disappears.
Regular exercise and physical ac�vity should be postponed during sick days.
- 69 -
Following condi�ons require hospitaliza�on:
o Vomi�ng or diarrhoea persis�ng for longer than 6 hours
o Sick for 3 days and not ge�ng be�er
o Blood glucose remains above 14 mmol/L for 6 hours
o Presence of ketonuria
o Very young individual, individuals with T1DM and pregnant ones
o Abdominal pain
o Hyperven�la�on or breathing difficul�es
o Confusion or feeling drowsy
o Co-exis�ng serious diseases like ESRD, heart failure etc.
6.6 Ramadan fasting13

6.6.1 Pre-Ramadan assessment
The persons with diabetes should receive a pre-Ramadan assessment ideally 6-8 weeks
before the start of Ramadan.
A detailed medical history on individuals should be obtained.
Individual seeking to fast should be categorized as ‘high’, ‘moderate’ or ‘low’ risks based
on the IDF-DAR Prac�cal Guidelines 2021.
Advice should be provided whether fas�ng is safe or not based on the risk category.
Management plan should be individualized.
To ensure safe fas�ng Ramadan-focused educa�on is required consis�ng of:
o Diet plan
o Exercise pa�ern
o The frequency of SMBG
o When to break the fast
o Ramadan-oriented medica�on adjustment
- 70 -
6.6.2 Ramadan nutrition plan (RNP)
Should be individualized to an individual’s lifestyle requirements, age, comorbidi�es and
other medical needs.
Adequate daily calories should be divided between suhoor and i�ar and 1-2 healthy snacks.
Meals should be well balanced, with around 40–50% carbohydrates, preferably of a low GI
source; the protein content (legumes, pulses, fish, poultry, or
lean meat) should comprise 20–30%; and fat should comprise 30-35% ; saturated fat
should be limited to <10% of total calorie sugar-rich desserts should be avoided a�er i�ar
and between meals.
Low GI carbohydrate should be selected, par�cularly those high in fibre (preferably whole
grains). The consump�on of carbohydrates from vegetables, whole fruits, yogurt, milk and
dairy products are encouraged and from sugar and highly processed grains (wheat flour
and starches like corn, white rice, and potatoes) should be avoided or minimized.
Food rich in protein and good quality fat can be�er induce sa�ety than food rich in
carbohydrates.1
Table 6.7 Calorie and carbohydrate distribu�on during Ramadan
Calorie (%) Carbohydrate distribution

Suhoor 30-40% 3-5 exchanges (45-75 g)
I�ar snack (before Margib prayer) 10-20% 1-2 exchanges (15-30 g)
I�ar meal (a�er Magrib prayer) 40-50% 3-6 exchanges (45-90 g)
Healthy snack (if required) 10-20% 1-2 exchanges (15-30 g)
6.6.3 Exercise during Ramadan

Physical activity should be reduced during day �me
Exercise can be performed a�er i�ar or a�er tarawih
Increased prayer during Ramadan should be taken into account while making plan for
exercise
- 71 -
Table 6.8 Non-insulin an�diabe�c agent dose adjustment
Name of drugs Dose modification during Ramadan

Me�ormin Once daily me�ormin: no dose modifica�on, should be taken at
i�ar.
Twice daily me�ormin: no dose modifica�on, should be taken at
i�ar and suhoor.
Thrice daily me�ormin: Morning dose to be taken at suhoor and
a�ernoon and evening dose combinedly at i�ar.
Sulfonylureas Once daily dosing: should be taken at i�ar and if blood glucose level
well-controlled dose reduc�on should be considered.
Twice daily dosing: i�ar dose remains the same as morning dose
and suhoor dose should be 50% of the evening dose.
Short ac�ng insulin Can be taken before i�ar and suhoor.
secretagogues Dose may be reduced or redistributed to two doses based on meal
(repaglinide) size.
DPP4 inhibitors No dose adjustment needed.
SGLT2 inhibitors SGLT2 inhibitors to be taken at i�ar.
Increased fluid intake is recommended.
Should be cau�ous when diure�cs are concomitantly used.
Do not require any dose adjustment.
Should not be ini�ated just before or during Ramadan.
Alpha-glucosidase No dose modifica�on is required.
inhibitors Can be taken at i�ar or at suhoor.
(acarbose,
voglibose, miglitol)
Thiazolidinediones No dose modifica�on is required.
(pioglitazone)
GLP1-RA liraglu�de and lixisena�de were found to be safe as an add-on
treatment to pre-exis�ng an�diabe�c regimens including
me�ormin and insulin during Ramadan.
Use of newer GLP1-RAs (such as dulaglu�de and albiglu�de) during
Ramadan is yet not evidence-based.
If liraglu�de, lixisena�de, exena�de have been appropriately dose-
�trated at least 2–4 weeks prior to Ramadan, no further treatment
modifica�ons are required.
- 72 -
Table 6.9 Insulin dose modifica�on during Ramadan
Name of drugs Dose modification during Ramadan

Basal insulin There is an increasing body of evidence suppor�ng the safety of basal
insulin during Ramadan.
Glycemic control can be successfully intensified with newer basal
insulin analogue like glargine in the Ramadan without risk of
hypoglycemia.
The dose of once daily NPH should be reduced by 15-30% and should
be taken at i�ar.
In case of twice daily NPH/detemir/glargine, usual morning dose should
be taken at i�ar and 50 % reduced evening dose should be taken at
suhoor.
Short ac�ng Normal dose should be taken at i�ar.
insulin Lunch-�me dose can be omi�ed.
Evening dose should be reduced to 50% at suhoor.
Pre-mixed insulin Once daily pre-mixed insulin should be taken at usual dose at i�ar.
In case of twice daily pre-mixed insulin, usual morning dose should be
taken at i�ar and suhoor dose should be reduced by 50% of evening
dose.
6.6.4 SMBG
Before i�ar, 2 hours a�er i�ar, mid-day and during any illness or symptoms of
hypoglycemia.
Frequency of SMBG should be daily for first 3 days, every 3 rd day from next week onwards
and every alternate day in the last week.
6.6.5 When to break the fast

All individuals willing to fast should be advised to break the fast if:
Blood glucose 3.9 mmol/L
Blood glucose levels 16.6 mmol/L (for those with sudden rise of blood glucose level)
Symptoms of hypoglycemia or acute illness occur
- 73 -
6.7 Hajj and Travel14,15
Risk stra�fica�on, medica�on adjustments, proper clinical assessment, and educa�on before
doing the Hajj are crucial.
6.7.1 Health risks

Hypoglycemia
Dehydra�on
Foot injuries and infec�on
Hyperglycemia
Heat stroke and heat exhaus�on
Infec�on
Cardiac problems
6.7.2 General recommendations

Before travel
To consult physician 1-2 months before the Hajj.
To complete recommended vaccina�ons.
It is preferable to pack diabetes medica�ons in carry-on bags, not in the checked luggage.
This will protect the medicines from temperature changes in luggage stored in cargoes,
which may affect the potency of insulin and other medica�ons.
To choose shoes, sandals, and flip-flops with appropriate shapes and sizes (wide-front shoe
to avoid extra pressure on the feet and the toes during long walking). Use socks while
barefoot walking is required.
During travel and Hajj

Some carbohydrates to be carried for use during hypoglycemia. Meals should not be
skipped.
Should drink plenty of water.
- 74 -
If using insulin, before Ihram should check blood glucose using glucometer and urine
ketone using dips�ck (for T1DM). If needed, a small dose of insulin to cover for
hyperglycemia and/or small meal to avoid hypoglycemia should be kept always.
If using insulin before and during long walking, decrease the dose of short and intermediate
insulin about 20% or more depending on the distance and effort. For those on sulfonylurea
drugs, this adjustment of daily dose (up to 50% decrease in the corresponding drug dose
of previous dose) can be applied.
Before tawaf (circumambula�on around Ka’bah) and saee (walking between Safa and
Marwah), should consume some addi�onal carbohydrates (Complex carbohydrate is
preferred) if the blood sugar within target.
Should check feet daily before going to bed.
6.7.3 Medication adjustment

Me�ormin, alpha-glucosidase inhibitors, thiazolidinediones, dipep�dyl pep�dase-4 (DPP4)
inhibitors, glucagon-like pep�de-1 (GLP1) receptor agonists and SGLT2 inhibitors require
no dose adjustment.
Sulfonylureas should be used with cau�on. The dose may be adjusted before doing the Hajj
physical ac�vity, and newer genera�ons are preferred.
Insulin treatment is usually linked to increased risk of hypoglycemia, especially during the
Hajj and its prolonged walking.
6.8 Diabetes and infection16,17

There is increased risk of infec�on in persons with diabetes. However, infec�on may
worsen diabetes control. Hyperglycemia impairs humoral immunity and leukocyte
func�ons. Persons with long-standing diabetes tend to have vasculopathy with resultant
poor �ssue perfusion. Moreover, diabe�c neuropathy results in unno�ced injury – all of
which can precipitate infec�on.
The most common sites of infec�on in diabetes are the skin and urinary tract. Spread of
infec�on bone causing osteomyeli�s is common in diabetes. Lower urinary tract infec�ons
and acute pyelonephri�s are seen with greater frequency.
- 75 -
A few infec�ons, such as malignant o��s externa, rhinocerebral mucormycosis,
emphysematous pyelonephri�s and emphysematous cholecys��s occur almost exclusively
in persons with diabetes. Infec�on at insulin injec�on site, some�mes leading to abscess
forma�on, though not common, may add to the suffering of the person. Some an�diabe�c
drugs may precipitate infec�on – SGLT2 inhibitors can precipitate UTI and genital fungal
infec�on; DPP4 inhibitors, GLP1 receptor agonists and thiazolidinediones can precipitate
nasopharyngeal infec�ons.
Management of hyperglycemia is crucial not only to contain the infec�on, but also to
prevent fatal acute complica�ons of diabetes. Insulin is the best op�on to control diabetes
in presence of infec�on. In case of very minor infec�on non-insulin agents may be
con�nued with cau�ous supervision. At the same �me aggressive management of the
par�cular infec�on with appropriate an�bio�c should be ensured.
6.8.1 Tuberculosis18
Subjects with diabetes are three to five �mes at higher risk of ge�ng ac�ve tu berculosis
compared to those without diabetes. O�en they do not have classical features, are associated
with increased morbidity, drug resistance and relapse. On the other hand, tuberculosis can
cause glucose intolerance and lead to increased incidence of diabetes mellitus. Insulin is the
best op�on, specially during early phase, severe infec�on (like disseminated or military TB,
tubercular meningi�s), lean and thin pa�ents, while using steroid etc. Moreover, some an�-TB
drugs have interac�on with some OADs.
6.8.2 COVID-1919
People with diabetes have increased risk of ge�ng more severe form of COVID-19, though
there is no sufficient proof of increased incidence of, or death from, the disease. There is
increased risk of diabetes in individuals who have suffered from COVID-19. For control of blood
glucose insulin is the best choice in case of moderate to severe disease. For cri�cally ill COVID-
19 pa�ents, specific protocol should be followed for glycemic control. For mild cases non-
insulin agents may be used with close monitoring.
- 76 -
6.9 Vaccination for people with diabetes20,21
As individuals with diabetes represent a vulnerable subgroup of the popula�on with respect to
suscep�bility to infec�on, preven�ng these infec�ons by means of vaccina�on assumes
paramount importance and is recommended by many interna�onal organiza�ons.
Table 6.10 Highly recommended immuniza�ons for individuals with diabetes
Vaccine Recommendations in diabetes
Children should be vaccinated with 13-valent pneumococcal conjugate

vaccine (PCV13) before the age of 2 years.
Pneumonia People with diabetes aged 2-64 years should receive 23-valent
pneumococcal polysaccharide vaccine (PPSV23). Booster dose is needed
a�er age 65.
Annual vaccina�on with influenza vaccine (preferably quadrivalent vaccine)

Influenza
is recommended for all people 6 months of age and above.
Administer a 2- or 3-dose series of hepa��s B vaccine, depending on the

vaccine, to unvaccinated adults with diabetes ages 18 through 59 years.
Hepa��s B
Consider administering a 3-dose series of hepa��s B vaccine to
unvaccinated adults with diabetes ≥60 years of age.
Human Papilloma 3 doses over 6 months, for <26 years of age; 27-45 years of age may also
Virus (HPV) be vaccinated against HPV a�er a discussion with health care provider.
Tetanus,
Booster every 10 years for all adults; pregnant women should have an
Diphtheria,
extra dose.
Pertussis (TDAP)
- 77 -
References
2022;45(1):90-92.
2. Mahtab H, Pathan MF, Ahmed T, Bajaj S, Sahay R, Raza SA, et al,. The Dhaka Declara�on
2015. Indian J Endocrinol Metab. 2015;19(4):441-2.
3. Raza SA. GDM: SAFES recommenda�on and Ac�on Plan. J Pak Med Assoc. 2018;68 (4):S1-
S23. PMID: 29808075.
4. Ryan EA, Al-Agha R. Glucose control during labor and delivery. Curr Diab Rep.
2014;14(1):450. doi: 10.1007/s11892-013-0450-4.
5. Mayer-Davis EJ, Kahkoska AR, Jefferies C, Dabelea D, Balde N, Gong CX, Aschner P, Craig
ME. ISPAD Clinical Prac�ce Consensus Guidelines 2018: Defini�on, epidemiology, and
classifica�on of diabetes in children and adolescents. Pediatr Diabetes. 2018;19:7-19. doi:
10.1111/pedi.12773.
6. Zeitler P, Arslanian S, Fu J, Pinhas-Hamiel O, Reinehr T, Tandon N, Urakami T, Wong J,
Maahs DM. ISPAD Clinical Prac�ce Consensus Guidelines 2018: Type 2 diabetes mellitus in
youth. Pediatr Diabetes. 2018;19:28-46. doi: 10.1111/pedi.12719.
7. American Diabetes Associa�on; 12. Older Adults: Standards of Medical Care in Diabetes—
2019. Diabetes Care 1 January 2019; 42 (Supplement_1): S139–
S147. h�ps://doi.org/10.2337/dc19-S012.
8. Korytkowski MT, Muniyappa R, An�nori-Lent K, Donihi AC, Drincic AT, Hirsch IB, Luger A, et
al. Management of Hyperglycemia in Hospitalized Adult Pa�ents in Non-Cri�cal Care
Se�ngs: An Endocrine Society Clinical Prac�ce Guideline. J Clin Endocrinol Metab. 2022
;107(8):2101-2128. doi: 10.1210/clinem/dgac278.
9. Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, et al. American
Associa�on of Clinical Endocrinologists; American Diabetes Associa�on. American
Associa�on of Clinical Endocrinologists and American Diabetes Associa�on consensus
statement on inpa�ent glycemic control. Endocr Pract. 2009;15:353-69. doi:
10.4158/EP09102.RA.
10. Duggan EW, Carlson K, Umpierrez GE. Periopera�ve Hyperglycemia Management: An
Update. Anesthesiology. 2017;126:547-560. doi: 10.1097/ALN.0000000000001515.
- 78 -
11. Gosmanov AR, Umpierrez GE. Management of hyperglycemia during enteral and
parenteral nutri�on therapy. Curr Diab Rep. 2013;13:155-62. doi: 10.1007/s11892-012-
0335-y.
12. How to manage diabetes during an illness? “SICK DAY RULES” h�ps://www.idf.org.
13. IDF DAR Prac�cal Guideline 2021 h�ps://www.daralliance.org/daralliance/idf-dar-
prac�cal-guidelines-2021
14. Ibrahim M, Abdelaziz SI, Abu Almagd M, Alarouj M, Annabi FA, Armstrong DG, et al.
Recommenda�ons for management of diabetes and its complica�ons during Hajj (Muslim
pilgrimage). BMJ Open Diabetes Res Care. 2018;6(1):e000574. doi: 10.1136/bmjdrc-2018-
000574.
15. Alsafadi H, Goodwin W, Syed A. Diabetes care during Hajj. Clin Med (Lond). 2011;11:218-
21. doi: 10.7861/clinmedicine.11-3-218.
16. Carey IM, Critchley JA, DeWilde s, et al. Risk of Infec�on in Type 1 and Type 2 Diabetes
Compared with General Popula�on: A Matched Cohort Study. Diabetes Care 2018;41:513.
17. Delamaire M, Maugendre D, Moreno M, Le Goff MC, Allannic H, Genetet B. Impaired
leucocyte func�ons in diabe�c pa�ents. Diabet Med. 1997;14(1):29-34.
18. Bhowmik B, Ahmed T, Afsana F, Qureshi NK, Siddiquee T, Khan AA, et al. Guide on
diabetes and COVID-19 for healthcare professionals in Bangladesh. J Diabetol 2020;11:137-
43.
19. Hossain MD, Ahmed JU, Rahim MA, Musa AK, La�f ZA. Bangladesh na�onal guidelines on
the management of tuberculosis and diabetes mellitus Co-morbidity (summary). Indian J
Endocrinol Metab. 2016;20(6):853-857. doi: 10.4103/2230-8210.192898.
20. Standards of Medical care in Diabetes, ADA (American Diabetes Associa�on), 2022.
21. American Associa�on Of Clinical Endocrinologists And American College Of Endocrinology
-Clinical Prac�ce Guidelines For Developing A Diabetes Mellitus Comprehensive Care Plan
– 2015 (endocrineprac�ce.org).
- 79 -
Chapter -7
Prevention
of
Diabetes Mellitus
- 80 -
CHAPTER-7
Prevention of Diabetes Mellitus
Executive summary
Type 2 diabetes is a preventable disease.
Preven�ons applicable in T2DM are primordial, primary, secondary and ter�ary preven�on.
Primary preven�on is very much feasible and cost effec�ve.
T2DM is a preventable disease. Its complica�ons can also be prevented or delayed. And
outcome of these preven�ve measures are immense on individual and also on the society. S�ll
now T1DM is not preventable.
7.1 Goals of diabetes prevention

Preven�ng or delaying the onset of diabetes by risk reduc�on
Preven�ng or delaying microvascular and macrovascular complica�ons
Ul�mately, ensuring socially produc�ve life and reducing economic burden of diabetes care
7.2 Types of prevention of diabetes

Primordial preven�on: focuses on strategies to stop the emergence of the risk factors
during the phase of normal glucose tolerance.
Primary preven�on: refers to avoiding the onset of the disease (diabetes).
Secondary preven�on: means early detec�on of diabetes and prompt ini�a�on of
treatment to prevent complica�ons of diabetes.
Ter�ary preven�on: aims to delay and/or prevent further progression of the diabe�c
complica�ons.
- 81 -
7.3 Primary prevention of T2DM
Interven�ons in high risk individuals is a very effec�ve strategy, and more cost effec�ve than
approaches in general popula�on.
7.3.1 Identification of high risk individuals

Several risk factors that put a person vulnerable to T2DM:
Family history of diabetes (in 1st degree rela�ves)
Over-weight and obesity
Unhealthy diet
Physical inac�vity
Increasing age (male>female)
High blood pressure
Dyslipidemia
Prediabetes
Polycys�c Ovary Syndrome (PCOS)
Persons with features of insulin resistance i.e. acanthosis nigricans, severe obesity
History of gesta�onal diabetes
History of poor nutri�on during pregnancy
It is possible to measure quan�ta�ve risk core from these to predict future diabetes.
7.3.2 Interventions for primary prevention

An intensive lifestyle interven�on could reduce the risk of incident T2DM by 58% over 3 years.1
Nutritional strategy
Healthy ea�ng in terms of type and calorie content needs to be ensured.
Vegetables, fresh fruits, whole-grain bread and rice, lean cuts of white meat, poultry,
seafood and unsaturated fats should be chosen.
Personal and cultural preferences, willingness and ability should be emphasized;
maintaining the pleasure of ea�ng is important.
- 82 -
Physical activity
The goal for physical ac�vity is at least 150 minutes of moderate-intensity physical ac�vity
per week similar in intensity to brisk walking. Around 30 minutes walking for 5 days a week
can serve the purpose.
In addi�on to aerobic ac�vity, an exercise regimen designed to prevent diabetes may
include resistance training.
Breaking up prolonged sedentary �me may also be encouraged.
The preven�ve effects of exercise appear to extend to the preven�on of gesta�onal
diabetes mellitus.2
Weight management
Over-weight/obesity is a well-known notorious factor in diabetogenesis.
Maintaining desirable body weight can be achieved through healthy meal plan and proper
exercise program.
Pharmacologic interventions
Me�ormin therapy for preven�on of T2DM should be considered in adults with prediabetes,
especially those aged 25-59 years with BMI ≥30 kg/m2, higher fas�ng plasma glucose (e.g. ≥110
mg/dL), and higher HbA1c (e.g. ≥6.0%), and in women with prior gesta�onal diabetes mellitus.
7.4 Secondary prevention

This encompasses early detec�on and prompt adequate treatment of diabetes. Early
detec�on of diabetes is important because control of hyperglycemia early in the
course of the disease may be crucial in preven�ng or delaying chronic complica�ons.
Majority of people with T2DM are asymptoma�c, and may remain so for many years. Many
persons with T2DM present with complica�ons. For early detec�on regular and proper
screening tests should be carried out. If found normal, test should be repeated every 3 years.
In case of prediabetes and previous GDM, tes�ng should be done every year. If found diabe�c,
interven�ons to prevent complica�ons are to be undertaken.
- 83 -
7.4.1 Interventions for secondary prevention
These are actually target based treatment of diabetes. Intensive management of blood
glucose and blood pressure reduces the risk of developing complica�ons of diabetes;3
lipid lowering reduces risk of coronary events. Foot care educa�on reduces risk of
ulcera�on. Cessa�on of smoking and weight control a re also beneficial components in
secondary preven�on.
7.5 Tertiary prevention

In epidemiological terms, ter�ary preven�on aims to reduce the number and/or impact of
complica�ons. Strategies for ter�ary preven�on include regular screening for complica�ons
and then taking aggressive measures, e.g. laser therapy for diabe�c re�nopathy to prevent
progression to blindness; treatment with ACE inhibitors to slow down the progression
of nephropathy;4 treatment of foot ulcer to prevent amputa�on etc.
7.6 Prevention of GDM

It is well known that women with GDM as well as their infants are at increased risk of
developing T2DM and other cardio-metabolic diseases like obesity, hypertension and coronary
artery diseases.5 Again, GDM is a poten�ally preventable condi�on. Weight management,
healthy ea�ng and adequate exercise are effec�ve ways to reduce the risk of GDM.
References
1. Knowler WC, Barre�-Connor E, Fowler SE, et al.; Diabetes Preven�on Program Research
Group. Reduc�on in the incidence of type 2 diabetes with lifestyle interven�on or
me�ormin. N Engl J Med 2002; 346:393–403.
2. Healy GN, Dunstan DW, Salmon J, et al. Breaks in sedentary �me: beneficial associa�ons
with metabolic risk. Diabetes Care 2008; 31:661–666.
3. Heneghan C, Thompson M, Perera R. Preven�on of diabetes. BMJ. 2006; 333:764-5. doi:
10.1136/bmj.38996.709340.BE.
4. Mansour SE, Browning DJ, Wong K, Flynn HW Jr, Bhavsar AR. The Evolving Treatment of
Diabe�c Re�nopathy. Clin Ophthalmol. 2020; 14:653-678. doi: 10.2147/OPTH.S236637.
5. Alber� KG, Zimmet PZ. Defini�on, diagnosis and classifica�on of diabetes mellitus and its
complica�ons. Part 1: diagnosis and classifica�on of diabetes mellitus provisional report of
a WHO consulta�on. Diabet Med. 1998;15(7):539-53.
- 84 -

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National Guideline

Non Communicable Disease Control Programme

Non Communicable Disease Control Programme

Deputy Managing Editor:

Japan Interna�onal Coopera�on Agency Diabe�c Associa�on of Bangladesh

Mr. Zahid Maleque MP National Prof. AK Azad Khan

Task Force Members

Prof. Md. Robed Amin Prof. Md.Faruque Pathan

Dr.Shahjada Selim Dr.FazleAlahi Khan

Chapter-1 Dr. Bishwajit Bhowmik Chapter-2 Dr. Nazmul Kabir Qureshi

Chapter-3 Dr. Faria Afsana Chapter-4 Dr. Tareen Ahmed

Chapter-5 Prof. Md.Feroz Amin Chapter-6 Prof. Indrajit Prasad

Chapter-7 Dr.Shahjada Selim

Joi Bangla, Joi Bangabandhu

I look forward to the success of this guideline.

National Prof. AK Azad Khan

optimal control, and capacity building of the physicians is a time-demanding need.

I look forward to the success of this guideline.

Dr. Md. Anwar Hossain Howlader

Prof. Dr. ABM Khurshid Alam

Diabetes is a chronic lifelong disease. If undetected or uncontrolled, it can lead to life-threatening

Prof. Dr. Md. Robed Amin

Table 1.1 Classiﬁca�on of DM

1.3 Criteria of different types of DM1, 2, 4

Table 1.2 Diﬀerence between T1DM, T2DM and GDM

Type 1 DM Type 2 DM GDM

1.5 Pathophysiology1, 2, 4-6

1.5.2 Type 2 diabetes

1.6 Clinical presentation1, 2, 4, 6

Screening and Diagnosis

2.1 Screening for prediabetes and diabetes

2.1.2 Screening for prediabetes and diabetes in children

2.1.3 Screening for diabetes in women planning pregnancy and pregnant

2.1.4 Screening for T1DM

2.1.5 Screening in special populations

2.2 Diagnosis of prediabetes and diabetes

2.2.1 OGTT (gold standard test)

NB: *In presence of classical symptoms of hyperglycemia (polyuria, polydipsia, polyphagia,

Table 2.2 Diagnos�c criteria for hyperglycemia in pregnancy 6

Gestational diabetes mellitus Diabetes in pregnancy

Treatment of DM is always individualized. T1DM always requires insulin but the

Table 3.1 Factors to be considered before selec�on of an�diabe�c agent 1,2

Type of DM Degree of hyperglycemia

Blood (plasma) glucose Fas�ng/pre-meal <7.0 mmol/L

NB: Target of glycemic control may be individualized considering individual factors.

3.1 Treatment regimen and monitoring

Medical nutrition therapy

Warm up Muscle stretching Main exercise Cool down

Table 3.5 Exercise in special situa�ons2

Stable coronary heart Perform moderate intensity exercise.

LS + Metformin Asymptomatic Symptomatic

FBG / Premeal <7.0 mmol/L

Figure 3.1 Type 2 diabetes management algorithm

Table 3.6 Diﬀerent classes of OADs

Drug Advantages Hazards Limitations

Vildaglip�n 50 mg x 2 100 mg (in 2 doses)

NB: ac - before meal. pc - a�er meal.

Table 3.9 Classiﬁca�on of insulin

Table 3.10 Dose adjustment of injectable GLP1-RAs

• Common regimen of ini�a�on of insulin therapy

• To make the person conﬁdent about self injec�on of insulin

Twice daily injections