Diabetes Mellitus and Management

Diabetes mellitus is the defining chronic disease challenge of the UAE. With one of the highest prevalence rates in the world — approximately 17% of the adult population — and even higher rates among Emirati nationals, diabetes touches every aspect of clinical nursing practice in the Emirates. The DOH (UAE) examination tests not only the clinical management of diabetes but also the nursing care priorities for diabetic patients across all settings, from emergency management of hypoglycaemia and diabetic ketoacidosis to long-term care of patients with microvascular and macrovascular complications.

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🟢 Lite — Quick Review (1h–1d)

Rapid summary for last-minute revision before your exam.

Diagnostic Criteria for Diabetes:

• Fasting plasma glucose ≥ 126 mg/dL (7.0 mmol/L)
• OR 2-hour plasma glucose ≥ 200 mg/dL during OGTT (oral glucose tolerance test)
• OR HbA1c ≥ 6.5% (48 mmol/mol)
• OR Random plasma glucose ≥ 200 mg/dL in symptomatic patient

Diabetes Types — Key Differences:

Feature	Type 1	Type 2
Onset	Usually <30 years	Usually >40 years
Cause	Autoimmune beta cell destruction	Insulin resistance + relative insulin deficiency
Insulin	Absolute deficiency	Relative deficiency
Ketosis	Prone (DKA)	Usually not
Obesity association	Not typical	Very strong
C-peptide	Low/absent	Normal to high initially
Autoantibodies	GAD, IA-2, ZnT8	None

Hypoglycaemia — The Most Dangerous Short-Term Complication:

• Trigger: Too much insulin or oral hypoglycaemic, missed meal, excessive exercise, alcohol
• Adrenergic symptoms: Sweating, tremor, tachycardia, anxiety, hunger, pallor
• Neuroglycopenic symptoms: Confusion, slurred speech, personality change, seizures, coma
• Rule of 15: 15g fast-acting carbs → wait 15 min → recheck glucose → repeat if still <70 mg/dL

⚡ Exam Tip: Never discharge a hypoglycaemic patient who has been treated with IV dextrose or IM glucagon without observing them for at least 2 hours. Hypoglycaemia can recur as the insulin (or sulfonylurea drug) continues to act.

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🟡 Standard — Regular Study (2d–2mo)

Standard content for students with a few days to months.

1. Oral Hypoglycaemic Agents (OHAs)

Metformin (First-line for T2DM):

• Mechanism: ↓ Hepatic glucose production; ↑ insulin sensitivity
• Benefits: Weight neutral or weight loss; no hypoglycaemia; cardiovascular benefits; inexpensive
• Side effects: GI upset (take with food); lactic acidosis (rare but serious — contraindicated in renal failure, liver failure, sepsis)
• CI: eGFR < 30; metabolic acidosis; iodinated contrast studies (hold before and 48h after contrast)

Sulfonylureas (Gliclazide, Glipizide):

• Mechanism: Stimulates insulin secretion from pancreatic beta cells (beta cell exhaustion over time)
• Side effect: Hypoglycaemia (especially in elderly); weight gain
• CI: Type 1 DM; liver failure; sulfa allergy

DPP-4 Inhibitors (Sitagliptin, Linagliptin):

• Mechanism: ↑ Incretin levels → ↑ insulin secretion, ↓ glucagon (glucose-dependent)
• Advantages: Weight neutral; no hypoglycaemia; good tolerability

SGLT2 Inhibitors (Empagliflozin, Dapagliflozin):

• Mechanism: ↓ Renal glucose reabsorption → glucosuria
• Benefits: Weight loss; cardiovascular and renal protection; reduce heart failure hospitalisation
• Side effects: Genital mycotic infections (especially in women); urinary tract infections; diabetic ketoacidosis (euglycaemic DKA — DKA with near-normal glucose)
• CI: Type 1 DM; severe renal impairment

GLP-1 Receptor Agonists (Semaglutide, Liraglutide):

• Mechanism: ↑ Insulin secretion, ↓ glucagon, ↓ gastric emptying, ↑ satiety
• Benefits: Significant weight loss; cardiovascular protection
• Administration: Subcutaneous injection (weekly or daily); oral semaglutide also available
• Side effects: Nausea, vomiting; gallbladder disease; thyroid C-cell tumours (in rodents, uncertain in humans)

2. Insulin Therapy

Insulin Types:

Type	Onset	Peak	Duration	Examples
Rapid-acting	5–15 min	1–2 h	3–5 h	Insulin aspart, lispro
Short-acting	30 min	2–4 h	6–8 h	Regular insulin (Humulin R)
Intermediate-acting	1–2 h	4–8 h	12–18 h	NPH (Humulin N)
Long-acting	1–2 h	No peak	20–24 h	Glargine, detemir, degludec
Pre-mixed	Varies	Varies	Varies	Novomix 30, Humulin 30/70

Insulin Regimens:

• Basal-bolus: Long-acting (basal) once or twice daily + rapid-acting (bolus) before each meal — most physiological
• Twice daily mixed: Fixed-ratio mixtures before breakfast and dinner — simpler but less flexible
• Sliding scale: Variable regular insulin based on blood glucose level — controversial; does not address underlying insulin need

Insulin Storage:

• Unopened vials/cartridges: Refrigerate (2–8°C); valid until expiry
• In use: Can be kept at room temperature (below 30°C) for up to 28 days; avoid direct sunlight and freezing
• Never use insulin that has changed colour or contains particles

3. Acute Complications — Emergency Management

Diabetic Ketoacidosis (DKA) — Medical Emergency:

• Presentation: Polyuria, polydipsia, nausea, vomiting, abdominal pain, Kussmaul breathing (deep, rapid), dehydration, altered consciousness
• Triggers: Infection (UTI, pneumonia), missed insulin, new diagnosis, MI, stroke, medications (steroids)
• Management (per UAE MOHAP/DOH protocols):
  1. Fluid resuscitation: IV normal saline 0.9% (10–15 mL/kg in first hour); switch to 0.45% saline when Na⁺ corrected or if hyperglycaemia persists
  2. IV insulin: 0.1 units/kg/hr regular insulin infusion (mix 50 units in 50 mL NS = 1 unit/mL)
  3. Potassium replacement: Usually needed (insulin drives K⁺ into cells → hypokalaemia); add 20–40 mEq/L once K⁺ < 5.3 and urine output confirmed
  4. Monitoring: Capillary glucose every 1–2 hours; ABG or VBG every 4 hours; electrolytes (K⁺, Na⁺, bicarbonate) every 4 hours
  5. Resolution criteria: Glucose < 200 mg/dL; pH > 7.3; HCO₃⁻ > 18; anion gap closed

Hyperosmolar Hyperglycaemic State (HHS):

• More insidious onset; occurs in Type 2 DM
• More severe dehydration than DKA (average fluid deficit: 8–12 litres)
• No significant acidosis (pH > 7.3; HCO₃⁻ > 18)
• Serum osmolality markedly elevated (>320 mOsm/kg)
• Management: Similar to DKA but fluid resuscitation is even more critical; insulin is given but at lower dose (can start after initial fluid resuscitation)

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🔴 Extended — Deep Study (3m+)

Comprehensive coverage for students on a longer study timeline.

4. Diabetic Foot Ulcers — Nursing Management

The Pathway to Amputation: Peripheral neuropathy → foot deformity → abnormal pressure points → callus → skin breakdown → ulcer → infection → gangrene → amputation

IWGDF Risk Stratification:

• Risk 0: No neuropathy — annual review
• Risk 1: Neuropathy present — biannual review
• Risk 2: Neuropathy + foot deformity or ischaemia — quarterly review
• Risk 3: History of ulcer or amputation — more frequent

Nursing Responsibilities:

• Annual monofilament testing for neuropathy (10-g monofilament on 4 plantar sites + hallux)
• Foot examination at every visit: Skin condition, nails, deformities, pulses, sensation
• Patient education: Daily self-examination, appropriate footwear, never walking barefoot
• Offloading: Total contact cast, orthopaedic shoes, felted foam dressings
• Wound care: Moist wound environment, debridement, appropriate dressing
• Infection management: Broad-spectrum antibiotics if infected; culture-directed therapy

5. Diabetes in Pregnancy

Gestational Diabetes (GDM):

• Develops during pregnancy; affects 10–20% of pregnancies in UAE (high rate due to underlying DM prevalence)
• Screen at 24–28 weeks (or earlier if high risk)
• Diagnosis: 75 g OGTT — fasting ≥ 92 mg/dL, 1-hour ≥ 180, 2-hour ≥ 153 mg/dL

Management:

• First-line: Medical nutrition therapy and exercise
• Second-line: Metformin or insulin if glucose targets not met
• Target: Fasting 70–95 mg/dL; 2-hour postprandial 100–120 mg/dL

Pre-existing Diabetes in Pregnancy:

• Pre-conception counselling critical (optimise HbA1c < 6.5% before conception)
• Tight glycaemic control reduces risk of congenital malformations (especially important in first trimester)
• Insulin is the drug of choice in pregnancy (metformin increasingly used)
• Higher risk of: Pre-eclampsia, preterm labour, macrosomia, shoulder dystocia, neonatal hypoglycaemia

6. Diabetes and Ramadan Fasting

Ramadan fasting is one of the Five Pillars of Islam and exempts the sick. However, many diabetic patients in the UAE choose to fast, requiring careful nursing and medical preparation.

Patients who should NOT fast:

• Type 1 DM (high risk of DKA)
• Poorly controlled Type 2 DM (HbA1c > 8.5%)
• History of hypoglycaemia
• Acute illness
• Pregnancy

Nursing advice for fasting patients:

• Monitor blood glucose multiple times daily (including pre-dawn meal and sunset)
• Adjust medication timing with physician guidance (some medications moved to Iftar and Suhoor)
• Break the fast immediately if glucose < 70 mg/dL or > 300 mg/dL
• Avoid excessive carbohydrate intake at Iftar
• Drink plenty of water between sunset and dawn

Exam Watch: In a patient with diabetic foot ulcer and poorly controlled diabetes (HbA1c 10%), the DOH examiner might ask what the nurse’s priority is: optimise glycaemic control AND wound care simultaneously. Never treat one without addressing the other.

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