Diagnosis of type 1 SD. Differential diagnosis of diabetes mellitus with other diseases

Diagnosis of type 1 diabetes mellitus (insulin-dependent) in most cases is not difficult. The clinical picture, drawn up only on the basis of a patient survey, already suggests the presence of pathology. In most cases, laboratory tests only support the primary diagnosis.

Circulation of glucose in a healthy body.

Pathology appears as a result of the inability of the pancreas to produce insulin in sufficient quantities. Typical symptoms of the disease are weight loss and at the same time increased appetite, constant thirst, frequent and profuse urination, weakness, sleep disturbances. Patients have a pale skin color, a tendency to colds and infections. Pustular rashes often appear on the skin, and wounds do not heal well.

The listed symptoms are usually characteristic of type 1 disease. In this case, the pathology develops rapidly, often patients can even name the exact date of the onset of the first symptoms. The disease can manifest itself after severe stress or viral lesions. Insulin-dependent diabetes predominantly affects young people.

Laboratory research

The diagnosis of type 1 diabetes contains several important points. This is an interview and examination of the patient, as well as tests to determine the amount of sugar in the blood and urine. Normally, the amount of glucose varies up to 6.5 mmol / l. Normally, there should be no sugar in the urine.

The endocrinologist examines the skin (whether there are scratches, foci of inflammation) and the subcutaneous fat layer (it becomes thinner). To make the most correct diagnosis, it is necessary to do several laboratory tests with an interval of several days. If the disease is suspected, additional diagnostics of type 1 diabetes is performed.

Basic methods:

• a blood sugar test, done several times: on an empty stomach, as well as after eating, sometimes before bedtime;
• the measurement of glycated hemoglobin is carried out to determine the degree of the disease, normal values \u200b\u200bare 4.5-6.5% of the total hemoglobin, an increase in glycated hemoglobin indicates the presence of diabetes, but may signal iron deficiency;
• glucose tolerance test - the patient is given a glucose solution (75 g of glucose is diluted in 200 g of water), the analysis is carried out after 120 minutes, with the help of the test prediabetes can be separated from real diabetes;
• urine analysis for the presence of sugar - the ingress of glucose into the urine is caused by a significant concentration of sugar in the blood (over 10 units);
• in some cases, studies are prescribed to determine the insulin fraction, the disease is characterized by a low content of the free insulin fraction in the blood;
• measuring the level of acetone in the urine - often the disease causes metabolic disorders and ketoacidosis (the concentration of organic acids in the blood), using this test, the presence of ketone bodies in the secretions is determined.

To identify complications and make a prognosis of the disease, additional studies are prescribed: retinotherapy (examination of the fundus), excretory urography (determines the presence of nephropathy and renal failure), electrocardiogram (the state of the heart will be checked).

The blood glucose meter is the main tool for self-monitoring of the patient with diabetes.

Self-control for illness

Diabetes requires 24/7 glucose monitoring. Sugar readings can vary significantly over a 24 hour period. Fluctuations negatively affect health. You need to somehow constantly monitor your glucose level and respond appropriately to its changes.

What causes the change in indicators:

• emotional stress, and not only stress, but also excessive joy;
• the amount of carbohydrates in the food consumed.

You don't need to go to the hospital and donate blood for analysis every hour to track your blood sugar. The necessary research can be done at home as well. For this, there are blood glucose meters and express tests in the form of strips of paper and plastic.

Rapid tests are designed to measure blood and urine sugar. This type of research is considered approximate. The packaging with express tests includes lancets for puncturing a finger and scarifiers (for taking blood). A drop of blood is transferred to the reagent strip, after which its color changes. The reference scale is used to determine the approximate sugar level. The presence of sugar in urine is determined in a similar way.

More accurate readings are given by a glucometer. A drop of blood is placed on the plate of the apparatus, and the sugar level is displayed on its display. In addition to the listed home studies, you can use tests for finding acetone in urine. The presence of acetone in the secretions indicates serious disorders of the internal organs caused by insufficient sugar correction.

It should be noted that the readings of glucometers from different manufacturers may differ from each other. Therefore, doctors recommend comparing the readings of your device with the results obtained in the laboratory.

RCHD (Republican Center for Healthcare Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols MH RK - 2014

Insulin-dependent diabetes mellitus (E10)

Pediatrics, Pediatric Endocrinology

general information

Short description

Approved on
Expert Commission on Healthcare Development

Ministry of Health of the Republic of Kazakhstan

Diabetes mellitus (DM) is a group of metabolic (metabolic) diseases characterized by chronic hyperglycemia, which is the result of impaired insulin secretion, the action of insulin, or both of these factors.
Chronic hyperglycemia in diabetes is associated with damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart and blood vessels (WHO 1999, 2006 with amendments).

I. INTRODUCTORY PART

Protocol name: Type 1 diabetes mellitus

Protocol code:

ICD-10 code (s):

E10 insulin-dependent diabetes mellitus;

Abbreviations used in the protocol:

ADA - American Diabetes Association

GAD65 - antibodies to glutamic acid decarboxylase

HbAlc - glycosylated (glycated) hemoglobin

IA-2, IA-2 β - antibodies to tyrosine phosphatase

IAA - antibodies to insulin

ICA - Islet Cell Antibodies

AH - arterial hypertension

BP - blood pressure

ACE - angiotensin converting enzyme

APTT - activated partial thromboplastin time

ARBs - angiotensin receptor blockers

IV - intravenous

DKA - diabetic ketoacidosis

I / U - insulin / carbohydrates

IIT - Intensified Insulin Therapy

BMI - body mass index

IR - insulin resistance

IRI - immunoreactive insulin

HDL - high density lipoprotein

LDL - low density lipoprotein

UIA - microalbuminuria

INR - international normalized ratio
LMWH - continuous glucose monitoring
NPII - continuous subcutaneous insulin infusion
UAC - complete blood count
OAM - general urine analysis
LE - life expectancy
PC - prothrombin complex
RAE - Russian Association of Endocrinologists
RKF - soluble fibrinomonomer complexes
ROO AVEC - Association of Endocrinologists of Kazakhstan
DM - diabetes mellitus
Type 1 diabetes - type 1 diabetes mellitus
Type 2 diabetes - type 2 diabetes mellitus
GFR - glomerular filtration rate
ABPM - 24-hour blood pressure monitoring
SMG - daily glucose monitoring
CCT - hypoglycemic therapy
TG - thyroglobulin
TPO - thyroid pyroxidase
TSH-thyroid-stimulating globulin
USDG - Doppler ultrasound
Ultrasound - ultrasound examination
FA - physical activity
XE - grain units
CS - cholesterol
ECG - electrocardiogram
ENG - electroneuromyography
Echocardiography - echocardiography

Date of protocol development: year 2014.

Protocol users: endocrinologists, therapists, pediatricians, general practitioners, emergency doctors.

Classification

Clinical classification

Table 1 Clinical classification of CD

SD type 1	Destruction of β-cells of the pancreas, usually leading to absolute insulin deficiency
SD type 2	Progressive impairment of insulin secretion against the background of insulin resistance
Other specific types of diabetes	- genetic defects in β-cell function; - genetic defects in insulin action; - diseases of the exocrine pancreas; - induced by drugs or chemicals (in the treatment of HIV / AIDS or after organ transplantation); - endocrinopathy; - infections; - other genetic syndromes associated with diabetes
Gestational diabetes	occurs during pregnancy

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES OF DIAGNOSTICS AND TREATMENT

List of basic and additional diagnostic measures

The main diagnostic measures at the outpatient level:

Determination of ketone bodies in urine

SMG or NMG (in accordance with Appendix 1);

Determination of glycosylated hemoglobin (HbAlc).

Additional diagnostic measures at the outpatient stage:

ELISA determination ICA - antibodies to islet cells, GAD65 - antibodies to glutamic acid decarboxylase, IA-2, IA-2 β - antibodies to tyrosine phosphatase, IAA - antibodies to insulin;

Determination of C-peptide in blood serum by immunochemiluminescence;

ELISA - determination of TSH, free T4, antibodies to TPO and TG;

Ultrasound of the abdominal organs, thyroid gland;

Chest fluorography (according to indications - R-graphy).

The minimum list of examinations that must be carried out when referring to planned hospitalization:

Determination of fasting blood glucose and 2 hours after eating (with a glucometer);

Determination of ketone bodies in urine;

Basic (mandatory) diagnostic examinations conducted at the inpatient level

Glycemic profile: fasting and 2 hours after breakfast, before lunch and 2 hours after lunch, before dinner and 2 hours after dinner, at 10:00 pm and 3:00 am

Biochemical blood test: determination of total protein, bilirubin, AST, ALT, creatinine, urea, total cholesterol and its fractions, triglycerides, potassium, sodium, calcium), GFR calculation;

UAC with leukoformula;

Determination of protein in urine;

Determination of ketone bodies in urine;

Determination of MAU in urine;

Determination of creatinine in urine, calculation of albumin-creatinine coefficient;

Determination of glycosylated hemoglobin (HbAlc)

SMG (NMG) (in accordance with Appendix 1);

Additional diagnostic examinations carried out at the inpatient level (in case of emergency hospitalization, diagnostic examinations are not carried out at the outpatient level):

Ultrasound of the abdominal organs;

Determination of APTT in blood plasma;

Determination of MNOPC in blood plasma;

Determination of RKF in blood plasma;

Determination of TB in blood plasma;

Determination of fibrinogen in blood plasma;

Determination of sensitivity to antimicrobial drugs of isolated cultures;

Bacteriological research of biological material for anaerobes;

Determination of blood gases and blood electrolytes with additional tests (lactate, glucose, carboxyhemoglobin);

Determination of insulin and antibodies to insulin;

USDG of the vessels of the lower extremities;

Holter ECG monitoring (24 hours);

SMAD (24 hours);

X-ray of the feet;

ECG (12 leads);

Consultation of narrow specialists (gastroenterologist, vascular surgeon, therapist, cardiologist, nephrologist, ophthalmologist, neuropathologist, anesthesiologist-resuscitator);

Diagnostic measures carried out at the stage of an ambulance emergency:

Determination of the level of glycemia;

Determination of ketone bodies in urine.

Diagnostic criteria

Complaints and anamnesis

Complaints: thirst, frequent urination, weight loss, weakness, skin itching, severe general and muscle weakness, decreased performance, drowsiness.

Anamnesis: Type 1 diabetes, especially in children and young people, begins acutely, develops over several months or even weeks. The manifestation of type 1 diabetes can be provoked by infectious and other concomitant diseases. The peak incidence occurs in the autumn-winter period.

Physical examination
The clinic is caused by the symptoms of insulin deficiency: dry skin and mucous membranes, decreased skin turgor, "diabetic" blush, enlarged liver, the smell of acetone (or fruit smell) in the exhaled air, shortness of breath, noisy breathing.

Up to 20% of patients with type 1 diabetes at the onset of the disease have ketoacidosis or ketoacidotic coma.

Diabetic ketoacidosis (DKA) and ketoacidotic coma DKA - acute diabetic decompensation of metabolism, manifested by a sharp increase in the level of glucose and the concentration of ketone bodies in the blood, their appearance in the urine and the development of metabolic acidosis, with varying degrees of impairment of consciousness or without it, requiring emergency hospitalization of the patient.

Stages of ketoacidosis :

Stage I ketoacidosis characterized by the appearance of general weakness, an increase in thirst and polyuria, an increase in appetite and, despite this, weight loss,

The smell of acetone in the exhaled air. Consciousness is preserved. Hyperglycemia, hyperketonemia, ketonuria +, pH 7.25-7.3 are characteristic.

When Stage II (precoma): an increase in these symptoms, shortness of breath appears, appetite decreases, nausea, vomiting, and abdominal pain are possible. Drowsiness appears with the subsequent development of a somnolent-soporous state. Characterized by: hyperglycemia, hyperketonemia, ketonuria + / ++, pH 7.0-7.3.

When Stage III (actually coma): there is a loss of consciousness, with a decrease or loss of reflexes, collapse, oligoanuria, severe symptoms of dehydration: (dry skin and mucous membranes (tongue "dry as a grater", dry lips, sticking in the corners of the mouth), Kussmaul breathing, signs of internal combustion - Syndrome (cold and bluish extremities, tip of the nose, auricles.) Laboratory parameters worsen: hyperglycemia, hyperketonemia, ketonuria +++, pH ˂ 7.0.

When carrying out insulin therapy for type 1 diabetes, physical exertion, insufficient intake of carbohydrates, patients with type 1 diabetes may experience hypoglycemic states.

Hypoglycemic conditions

The clinical picture of hypoglycemic conditions is associated with energy hunger in the central nervous system.
Neuroglycopenic symptoms:
... weakness, dizziness
... decreased concentration and attention
... headache
... drowsiness
... confusion
... fuzzy speech
... unsteady gait
... convulsions
... tremor
... cold sweat
... pallor of the skin
... tachycardia
... increase in blood pressure
... feelings of anxiety and fear

Severity of hypoglycemic conditions:

Mild: sweating, trembling, palpitations, anxiety, blurred vision, hunger, fatigue, headache, poor coordination, slurred speech, drowsiness, lethargy, aggression.

Severe: convulsions, coma. A hypoglycemic coma occurs if measures are not taken in time to stop a severe hypoglycemic state.

Laboratory research

Table 2. Diagnostic criteria for diabetes mellitus and other glycemic disorders (WHO, 1999, 2006, with additions)

* Diagnosis is based on laboratory glucose measurements.
** The diagnosis of diabetes should always be confirmed by re-determination of glycemia in the following days, except in cases of undoubted hyperglycemia with acute metabolic decompensation or with obvious symptoms. Diagnosis of gestational diabetes mellitus can be made on the basis of a single blood glucose test.
*** In the presence of classic symptoms of hyperglycemia.

Determination of blood glucose:
- fasting - means the glucose level in the morning, after preliminary fasting for at least 8 hours.
- random - means the glucose level at any time of the day, regardless of the time of the meal.

HbAlc - as a diagnostic criterion for diabetes :
The HbAlc level ≥ 6.5% (48 mmol / mol) was chosen as a diagnostic criterion for diabetes. An HbAlc level of up to 5.7% is considered normal, provided that it is determined by the National Glicohemoglobin Standardization Program (NGSP) method, according to the standardized Diabetes Control and Complications Trial (DCCT).

In the absence of symptoms of acute metabolic decompensation, the diagnosis should be made on the basis of two digits that are in the diabetic range, for example, double HbAlc or single HbAlc + single glucose.

Table 3. Laboratory indicators of diabetic ketoacidosis

Index	Normal	With DKA	Note
Glucose	3.3-5.5 mmol / l		Usually above 16.6
Potassium	3.8-5.4 mmol / l	N or	With intracellular potassium deficiency, its plasma level is initially normal or even elevated due to acidosis. With the onset of rehydration and insulin therapy, hypokalemia develops
Amylase	<120ЕД/л		Lipase remains within normal limits
Leukocytes	4-9x109 / l		Even in the absence of infection (stress leukocytosis)
Blood gas composition: pCO2	36-44 mm Hg	↓↓	Partial Respiratory Compensated Metabolic Acidosis
pH	7,36-7,42		With concomitant respiratory failure, pCO2 is less than 25 mm Hg. Art., while the expressed vasoconstriction of the vessels of the brain develops, possibly the development of cerebral edema. Decreases to 6.8
Lactate	<1,8 ммоль/л	N or	Lactic acidosis is caused by hyperperfusion, as well as the active synthesis of lactate by the liver under conditions of decreasing pH<7,0
KFK, AST			As a sign of proteolysis

Note. - increased, ↓ - decreased, N - normal value, CPK - creatine phosphokinase, AST - aspartate aminotransferase.

Table 4. Classification of DKA by severity

Indicators	DKA severity
	easy	moderate	heavy
Plasma glucose (mmol / l)	> 13	> 13	> 13
arterial blood pH	7.25 - 7.30	7.0 - 7.24	< 7.0
Serum bicarbonate (mmol / L)	15 - 18	10 - 15	< 10
Ketone bodies in urine	+	++	+++
Serum ketone bodies
Plasma osmolarity (mosmol / l) *	Varies	Varies	Varies
Anionic difference **	> 10	> 12	> 14
Impaired consciousness	Not	No or sleepiness	Stupor / coma

* For calculation see section Hyperosmolar hyperglycemic state.
** Anionic difference \u003d (Na +) - (Cl- + HCO3-) (mmol / L).

Indications for specialist consultation

Table 5. Indications for specialist advice *

Specialist	Objectives of the consultation
Ophthalmologist consultation	For the diagnosis and treatment of diabetic retinopathy: ophthalmoscopy with a wide pupil once a year, more often if indicated
Neurologist's consultation
Nephrology consultation	For the diagnosis and treatment of complications of diabetes - according to indications
Consultation with a cardiologist	For the diagnosis and treatment of complications of diabetes - according to indications

Differential diagnosis

Differential diagnosis

Table 6 Differential diagnosis of type 1 diabetes and type 2 diabetes

SD type 1	SD type 2
Young age, acute onset (thirst, polyuria, weight loss, presence of acetone in urine)	Obesity, hypertension, sedentary lifestyle, the presence of diabetes in the next of kin
Autoimmune destruction of β-cells of the islets of the pancreas	Insulin resistance combined with β-cell secretory dysfunction
In most cases - low level of C-peptide, high titer of specific antibodies: GAD, IA-2, islet cells	Normal, increased or slightly decreased blood levels of C-peptide, absence of specific antibodies: GAD, IA-2, islet cells

Treatment abroad

Undergo treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment goals
The goal of treating type 1 diabetes is to achieve normoglycemia, normalize blood pressure, lipid metabolism, and prevent complications of type 1 diabetes.
The choice of individual treatment goals depends on the patient's age, life expectancy, the presence of severe complications, and the risk of severe hypoglycemia.

Table 7 Algorithm for individualized selection of therapy goals according to HbAlc

* LE - life expectancy.

Table 8 These HbAlc target levels will meet the following pre / post-prandial plasma glucose targets

HbAlc **	Plasma glucose on an empty stomach / before meals, mmol / l	Plasma glucose 2 hours after meals, mmol / l
< 6,5	< 6,5	< 8,0
< 7,0	< 7,0	< 9,0
< 7,5	< 7,5	< 10,0
< 8,0	< 8,0	< 11,0

* These targets do not apply to children, adolescents, and pregnant women. Target values \u200b\u200bof glycemic control for these categories of patients are discussed in the relevant sections.
** Normal level according to DCCT standards: up to 6%.

Table 9 Indicators of lipid metabolism control

Indicators	Target values, mmol / l *
	men	women
General CS	< 4,5
LDL cholesterol	< 2,6**
HDL cholesterol	> 1,0	> 1,2
triglycerides	<1,7

* Conversion from mol / L to mg / dL: Total cholesterol, LDL cholesterol, HDL cholesterol: mmol / L × 38.6 \u003d mg / dL Triglycerides: mmol / L × 88.5 \u003d mg / dL
**< 1,8 - для лиц с сердечно-сосудистыми заболеваниями.

Table 10 Blood pressure control indicators

* Against the background of antihypertensive therapy

Measurement of blood pressure should be carried out at each visit to the endocrinologist. Patients with systolic blood pressure (SBP) values \u200b\u200b≥ 130 mm Hg. Art. or diastolic blood pressure (DBP) ≥ 80 mm Hg. Art., you should re-measure blood pressure on another day. If the mentioned values \u200b\u200bof blood pressure are observed upon repeated measurement, the diagnosis of hypertension is considered confirmed.

Treatment goals for children and adolescents with type 1 diabetes :
... reaching the level of carbohydrate metabolism as close to normal as possible;
... normal physical and somatic development of the child;
... development of independence and motivation for self-control of glycemia;
... prevention of complications of type 1 diabetes.

Table 11

Age groups			HbA1c level,%	Rational prerequisites
Preschoolers (0-6 years old)	5,5-10,0	6,1-11,1	<8,5, но >7,5
Schoolchildren (6-12 years old)	5,0-10,0	5,6-10,0	<8,5
	5,0-7,2	5,0-8,3	<7,5	- risk of severe hypoglycemia - maturation and psychological aspects - lower target values \u200b\u200b(HbA1c<7,0%) приемлемы, если достигаются без большого риска гипогликемий

Treatment tactics :

Insulin therapy.

Meal planning.

Self-control.

Drug-free treatment

Diet recommendations
Calculation of food for children: The energy requirement for a child under 1 year old is 1000-1100 kcal. The daily calorie intake for girls from 1 to 15 years old and boys from 1 to 10 years old is calculated by the formula: Daily calorie intake \u003d 1000 + 100 X n *

The daily calorie intake for boys from 11 to 15 years old is calculated using the formula: Daily calorie intake \u003d 1000 + 100 X n * + 100 X (n * - 11) where * n is age in years.
The total daily energy intake should be distributed as follows: carbohydrates 50-55%; fats 30-35%; proteins 10-15%. Considering that when 1 gram of carbohydrates is assimilated, 4 kcal is formed, the required grams of carbohydrates per day and the corresponding XE are calculated (table 12).

Table 12 Estimated daily requirement for XE depending on age

Calculation of food for adults:

The daily calorie intake is determined depending on the intensity of physical activity.

Table 13 Daily calorie intake for adults

Labor intensity	Categories	Energy amount
Easy labor	Workers of predominantly mental work (teachers, educators, except for physical education teachers, workers in science, literature and the press); Light manual workers (workers employed in automated processes, salespeople, service workers)	25-30 kcal / kg
Medium intensity labor	drivers of various types of transport, workers of public utilities, railway and water workers	30-35 kcal / kg
Hard physical labor	The bulk of agricultural workers and machine operators, miners on surface work; Workers engaged in particularly heavy physical labor (bricklayers, concrete workers, excavators, loaders, whose work is not mechanized)	35-40 kcal / kg

The total daily energy intake should be distributed as follows: carbohydrates - 50%; proteins - 20%; fats - 30%. Considering that when 1 gram of carbohydrates is assimilated, an energy of 4 kcal is formed, the required grams of carbohydrates per day and the corresponding XE are calculated (table 14).

Table 14 Estimated need for carbohydrates (XE) per day

To assess digestible carbohydrates according to the XE system in order to adjust the dose of insulin before meals for children and adults, use the table "Replacement of products according to the XE system" (Appendix 2).
It is recommended to limit protein intake to 0.8-1.0 g / kg body weight per day in people with diabetes and early stages of chronic kidney disease and to 0.8 g / kg body weight per day in patients with advanced stages of chronic kidney disease. as such measures improve renal function (indicators of urinary albumin excretion, GFR).

Physical activity recommendations
FA improves the quality of life, but is not a method of glucose-lowering therapy in type 1 diabetes. FA is selected individually, taking into account the patient's age, diabetes complications, concomitant diseases, and tolerance.
FA increases the risk of hypoglycemia during and after exercise, therefore the main task is to prevent hypoglycemia associated with FA. The risk of hypoglycemia is individual and depends on the initial glycemia, insulin dose, type, duration and intensity of PA, as well as the degree of fitness of the patient.

Prevention of hypoglycemia in short-term PA (no more than 2 hours) - additional intake of carbohydrates:

Measure glycemia before and after FA and decide if you need to additionally take 1-2 XE (slowly digestible carbohydrates) before and after FA.

If baseline plasma glucose is\u003e 13 mmol / L or if PA occurs within 2 hours after a meal, additional XE is not required before PA.

In the absence of self-control, it is necessary to take 1-2 XE before and 1-2 XE after FA.

Prevention of hypoglycemia with prolonged PA (more than 2 hours) - a decrease in the dose of insulin, therefore, long-term loads should be planned:

Reduce the dose of short- and long-acting insulin preparations that will act during and after PA by 20-50%.

For very long and / or intense PA: reduce the dose of insulin that will act at night after PA, sometimes the next morning.

During and after prolonged PA: additional self-control of glycemia every 2-3 hours, if necessary - taking 1-2 XE of slowly digestible carbohydrates (with plasma glucose< 7 ммоль/л) или быстро усваиваемых углеводов (при уровне глюкозы плазмы < 5 ммоль/л).

Patients with type 1 diabetes, conducting self-control and proficient in methods of preventing hypoglycemia, can engage in any type of PA, including sports, taking into account the following contraindications and precautions:

Temporary contraindications to FA:

Plasma glucose levels above 13 mmol / L in combination with ketonuria or above 16 mmol / L, even without ketonuria (in conditions of insulin deficiency, FA will increase hyperglycemia);

Hemophthalmus, retinal detachment, the first six months after laser coagulation of the retina; uncontrolled arterial hypertension; Ischemic heart disease (in agreement with the cardiologist).

Glycemia monitoring
Self-control - regular monitoring of glycemia by trained patients or members of their families, analysis of the results obtained, taking into account diet and physical activity, the ability to independently correct insulin therapy depending on the changing conditions of the day. Patients should independently measure blood glucose levels before main meals, postprandially, before bedtime, before and after physical exertion, if hypoglycemia is suspected and after its relief. The optimal determination of glycemia is 4-6 times a day.
When prescribing a method for self-monitoring of glucose levels to a patient, it is necessary to make sure that the patient understands the instructions for its use, can use it and, based on the results obtained, correct the treatment. An assessment of the patient's ability to use the self-control method should be carried out during the observation process.

Goals of Blood Glucose Self-Monitoring:
... monitoring changes in emergency situations and assessing daily levels of control;
... interpretation of changes in assessing immediate and daily insulin requirements;
... selection of a dose of insulin to reduce fluctuations in glycemic levels;
... detection of hypoglycemia and its correction;
... correction of hyperglycemia.

SMG system is used as a modern method for diagnosing changes in glycemia, detecting hypoglycemia, correcting treatment and selecting antihyperglycemic therapy; promotes patient education and participation in their care (Appendix 1).

Patient education
Education of patients with diabetes is an integrating component of the treatment process. It should provide patients with the knowledge and skills to help them achieve specific therapeutic goals. Educational activities should be carried out with all patients with diabetes from the moment the disease is detected and throughout its duration.
The goals and objectives of training should be specified in accordance with the current state of the patient. For training, specially designed structured programs are used, addressed to patients with type 1 diabetes and / or their parents (including training on insulin pump therapy). Education should include psychosocial aspects, as emotional health is closely related to a favorable prognosis for diabetes.
Training can be carried out both individually and in groups of patients. The optimal number of patients in a group is 5-7. Group teaching requires a separate room in which silence and adequate lighting can be ensured.
Diabetes schools are created on the basis of polyclinics, hospitals and consultative and diagnostic centers on a territorial basis. 1 school is created in each endocrinology department of the hospital.
Patient education is carried out by specially trained medical workers: an endocrinologist (diabetologist), a nurse.

Drug therapy

Insulin therapy for type 1 diabetes
Insulin replacement therapy is the only treatment for type 1 diabetes.

Insulin delivery modes :
... Basic bolus regimen (intensified regimen or multiple injection regimen):
- basal (medium-duration insulin preparations and peakless analogs, with pump therapy - ultra-short-acting drugs);
- bolus (short-acting and ultra-short-acting insulin preparations) for food intake and / or correction (to reduce high blood glucose levels)

The mode of continuous subcutaneous insulin infusion using an insulin pump allows the level of insulinemia to be as close to physiological as possible.

... During the period of partial remission, the insulin therapy regimen is determined by the blood glucose level. Correction of the insulin dose should be carried out daily, taking into account the data of self-control of glycemia during the day and the amount of carbohydrates in food, until the target indicators of carbohydrate metabolism are achieved. Intensified insulin therapy, including multiple injection regimen and pump therapy, leads to a decrease in the incidence of vascular complications.

Table 15 Recommended insulin delivery devices

For children, adolescents, patients with a high risk of vascular complications, the first-line drugs are analogs of genetically engineered human insulin of ultrashort and long-acting. The best way to administer insulin is an insulin pump.

Insulin preparations by duration of action	Onset of action in, min	Peak action in, hour	Duration of action, hour
Ultra-short-acting (human insulin analogues) **	15-35	1-3	3-5
Short acting **	30-60	2-4	5-8
Long-term peakless action (insulin analog) **	60-120	Not expressed	Up to 24
Medium duration **	120-240	4-12	12-24

* Mixed human insulins are not used in pediatric practice.
** The use of the type of insulin in pediatric practice is carried out taking into account the instructions.

Insulin dose
... Each patient has an individual need for insulin and the ratio of insulin of different duration.
... In the first 1-2 years of the disease, the need for insulin averages 0.5-0.6 U / kg body weight;
... After 5 years from the onset of diabetes, in most patients, the need for insulin rises to 1 U / kg of body weight, and during puberty it can reach 1.2-1.5 U / kg.

Continuous subcutaneous insulin infusion (CPII)
Insulin pumps - means for continuous subcutaneous administration of insulin. It uses only one type of insulin, mainly a fast-acting analogue, which is delivered in two modes - basic and bolus. Thanks to NPII, it is possible to achieve blood sugar levels as close to normal as possible, but at the same time to avoid hypoglycemia. Today NPII is successfully used in children and pregnant women with diabetes.

In children and adolescents, the method of choice is the use of NPII with function continuous glucose monitoring due to the possibility of achieving the best glycemic control with a minimum risk of hypoglycemia. This method allows the diabetic patient not only to see changes in blood glucose on the display in real time, but also to receive warning signals of critical blood sugar levels and promptly change therapy, achieving good diabetes control with low glycemic variability in the shortest possible time.

Benefits of using insulin pumps:
Decline:
... Severe, moderate, and mild hypoglycemia
... Average concentration of HbA1c
... Fluctuations in glucose concentrations throughout the day and on different days
... Daily insulin dose
... The risk of developing microvascular disease

Improvement:
... Patient satisfaction with treatment
... Quality of life and health

Indications for using pump therapy:
... the ineffectiveness or inapplicability of the method of multiple daily injections of insulin, despite proper care;

Large variability of glycemia during the day, regardless of the level of HbA1c; labile course of diabetes mellitus;

... "Phenomenon of the morning dawn";
... decreased quality of life;
... frequent hypoglycemia;
... young children with low insulin requirements, especially infants and newborns; there is no age limit for the use of pumps; high sensitivity to insulin (insulin dose less than 0.4 U / kg / day);
... children with acuphobia;

Initial complications of diabetes;

Chronic renal failure, kidney transplant;

Diseases of the gastrointestinal tract, accompanied by gastroparesis;

Regular sports activities;
... pregnancy

Indications for the appointment of NPII in children and adolescents
Obvious indications
... Recurrent severe hypoglycemia
... Newborns, infants, toddlers and preschool children
... Suboptimal diabetes control (eg, HbA1c levels above target for age)
... Severe fluctuations in blood glucose levels regardless of HbA1c indicators
... Pronounced morning phenomenon
... Microvascular complications and / or risk factors for their development

Addiction to ketosis
... Good metabolic control, but treatment regimen is inappropriate

Other indications
... Teens with eating disorders
... Children with a fear of injections
... Skipping insulin injections
The pump can be used for any duration of diabetes, including at the onset of the disease.

Contraindications for transferring to insulin pump therapy:
... lack of compliance of the patient and / or family members: insufficient training or unwillingness or inability to apply this knowledge in practice;
... psychological and social problems in the family (alcoholism, asocial families, behavioral characteristics of the child, etc.); mental disorders;

Severe visual and / or hearing impairment in the patient;

Conditions for transferring to pump therapy:
... sufficient knowledge of the patient and / or family members;
... transfer in inpatient and outpatient conditions by a doctor with special training in pump therapy;

Conditions for terminating pump therapy:
... the child or parents (guardians) wish to return to traditional therapy;
... Medical indications: - frequent episodes of ketoacidosis or hypoglycemia due to improper pump control;
- ineffectiveness of pump therapy due to the patient's fault (frequent missed boluses, inadequate frequency of self-monitoring, lack of adjustments to insulin doses);
- frequent infection at the catheter insertion sites.

NPII application:
Ultrashort insulin analogs (lispro, aspart, or glulisine) are currently considered the insulin of choice for pump therapy, and dosages are estimated in the following way:
... Basal dose: The general initial approach is to reduce the total daily insulin dose with syringe therapy by 20% (in some clinics, the dose is reduced by 25-30%). Inject 50% of the total daily dose in pump therapy as a basal rate, divided by 24 to obtain a dose per hour. The number of basal rate levels is adjusted by monitoring blood glucose levels.

... Bolus insulin... The bolus doses are adjusted according to the measured postprandial blood glucose levels (1.5-2 hours after each meal). Carbohydrate counting is currently considered the preferred method in which the size of the bolus dose of insulin is estimated according to the carbohydrate content of the food, the insulin / carbohydrate ratio (I / C) depending on the individual patient and food, and the correction dose of insulin, the size of which is based on your pre-meal blood glucose level and how much it deviates from your target blood glucose level. The I / U ratio can be calculated as 500 / per total daily insulin dose. This formula is often referred to as the “rule of 500”. The correction dose used to correct a food bolus for pre-meal blood glucose and to correct unexpected hyperglycemia between meals is estimated using the insulin sensitivity factor (ISF), which is calculated in mmol / L as 100 / per total daily dose insulin ("rule of 100").

DKA treatment
Treatment of diabetes mellitus with severe DKA should be carried out in centers where there is a capacity to assess and monitor clinical symptoms, neurological status and laboratory parameters. Pulse, respiratory rate, blood pressure, neurological status, ECG monitoring are recorded hourly. An observation protocol is maintained (the results of all measurements of glucose in blood or plasma, ketone bodies, electrolytes, serum creatinine, pH and gas composition of arterial blood, glucose and ketone bodies in urine, volume of injected fluid, type of infusion solution, method and duration of infusion, fluid loss (diuresis) and insulin dose). At the beginning of treatment, laboratory parameters are determined every 1-3 hours, later - less often.

DKA treatment includes: rehydration, insulin administration, restoration of electrolyte disturbances; general measures, treatment of conditions that caused DKA.

Rehydration carry out with 0.9% NaCl solution to restore peripheral blood circulation. Children with DKA should be rehydrated more slowly and carefully than in other cases of dehydration.

DKA insulin therapy should be administered continuously by infusion using a low dose regimen. For this, it is better to use a dispenser (infusomat, perfuser). Small doses of intravenous short-acting insulin are used. The initial dose is 0.1 U / kg of body weight per hour (you can dilute 50 U of insulin in 50 ml of saline, then 1 U \u003d 1 ml). 50 ml of the mixture is jetted through the intravenous infusion system to absorb insulin onto the walls of the system. The insulin dose remains at the level of 0.1 U / kg per hour at least until the patient leaves the DKA (pH is more than 7.3, hydrocarbons are more than 15 mmol / L, or the anion difference normalizes). With a rapid decrease in glycemia and metabolic acidosis, the insulin dose can be reduced to 0.05 U / kg per hour or less. In young children, the initial dose may be 0.05 U / kg, and with severe concomitant purulent infection, it can increase to 0.2 U / kg per hour. In the absence of ketosis for 2-3 days - for intensified insulin therapy.

Potassium recovery... Replacement therapy is required regardless of the serum potassium concentration. Potassium replacement therapy is based on serum determinations and continues throughout the period of intravenous fluids.

Fight acidosis... Bicarbonates are used only in the case of severe acidosis (blood pH below 7.0), which threatens to suppress external respiration (at pH below 6.8), during a complex of resuscitation measures.

Patient monitoring... The glucose content in capillary blood is determined every hour. Every 2-4 hours, the level of glucose, electrolytes, urea, and blood gas composition is determined in the venous blood.

Complications of DC therapy: cerebral edema, inadequate rehydration, hypoglycemia, hypokalemia, hyperchloremic acidosis.

Treatment of hypoglycemic conditions
Patients who develop hypoglycemia without showing symptoms, as well as patients who have experienced one or more episodes of severe hypoglycemia, should be advised to focus on higher target glucose values \u200b\u200bto avoid hypoglycemia for at least several weeks, as well as with in order to partially eliminate the problem of the development of asymptomatic hypoglycemia and reduce the risk of hypoglycemic episodes in the future.

Mild hypoglycemia(not requiring the help of another person)

The use of glucose (15-20 g) is the preferred treatment in conscious patients with hypoglycemia, although any form of carbohydrate containing glucose can be used.

Reception of 1 XE of rapidly digestible carbohydrates: sugar (3-5 pieces of 5 g, better to dissolve), or honey or jam (1 tablespoon), or 100 ml of fruit juice, or 100 ml of lemonade with sugar, or 4-5 large tablets glucose (3-4 g each), or 1 tube with carbohydrate syrup (13 g each). If symptoms persist, repeat the intake of products after 15 minutes.

If hypoglycemia is caused by short-acting insulin, especially at night, then additionally eat 1-2 XE of slowly digestible carbohydrates (bread, porridge, etc.).

Severe hypoglycemia (requiring the help of another person, with or without loss of consciousness)
... Lay the patient on his side, free the oral cavity from food debris. In case of loss of consciousness, sweet solutions should not be poured into the oral cavity (danger of asphyxiation!).
... Introduce 40 - 100 ml of a 40% dextrose (glucose) solution in an intravenous stream until consciousness is fully restored. In severe cases, glucocorticoids are used intravenously or intramuscularly.
... An alternative is 1 mg (0.5 mg for small children) of glucagon s / c or i / m (administered by a relative of the patient).
... If consciousness is not restored after intravenous injection of 100 ml of 40% dextrose (glucose) solution, this indicates cerebral edema. Hospitalization of patients and intravenous administration of colloidal solutions at the rate of 10 ml / kg / day: mannitol, mannitol, hydroxyethyl starch (pentastarch) is required.
... If the cause is an overdose of oral glucose-lowering drugs with a long duration of action, continue the intravenous drip of 5-10% dextrose (glucose) solution until glycemia normalizes and the drug is completely removed from the body.

Rules for the management of patients with diabetes in intercurrent diseases
... Never stop insulin therapy!
... More frequent and careful monitoring of blood glucose and blood / urine ketone levels.
... Intercurrent disease is treated in the same way as in patients without diabetes.
... Diseases with vomiting and diarrhea are accompanied by a decrease in blood glucose levels. For the prevention of hypoglycemia - reduce the dose of short and prolonged insulin by 20-50%, light carbohydrate foods, juices.
... With the development of hyperglycemia and ketosis, correction of insulin therapy is necessary:

Table 17 Treatment for ketoacidosis

Blood glucose	Ketones in the blood	Correction of insulin therapy
More than 14 mmol / L	0-1mmol / l	Increasing the dose of short / ultra-short insulin by 5-10% of the total daily dose
More than 14 mmol / L	1-3mmol / l
More than 14 mmol / L	More than 3mmol / l	Increasing the dose of short / ultra-short insulin by 10-20% of the total daily dose

Table 18Treatment of painful form of DPN

Pharmacological group	ATX code	International name	Dosage, frequency, duration of admission	Evidence level
Anticonvulsants	N03AX16	Pregabalin	150 mg orally 2 r / day (up to 600 / day if necessary) duration of administration - individually, depending on the effect and tolerability	AND
	N03AX12	Gabapentin	1800-2400 mg / day in 3 divided doses (start with 300 mg, gradually increasing to a therapeutic dose)	AND
Antidepressants	N06AX	Duloxetine	60 mg / day (if necessary 120 / day in 2 divided doses) for 2 months	AND
	N06AA	Amitriptyline	25 mg 1-3 r / day (individually) duration of admission - individually, depending on the effect and tolerance	IN

Table 19 Treatment of therapy-resistant pain DPN

List of essential medicines (100% likely to be used):
ACE inhibitors, ARBs.

List of complementary medicines (less than 100% likely to be used)
Nifedipine;
Amlodipine;
Carvedilol;
Furosemide;
Epoetin alpha;
Darbepoetin;
Sevelamer carbonate;
Cinacalcet; Albumen.

Diabetic retinopathy treatment

Patients with macular edema, severe nonproliferative diabetic retinopathy, or proliferative diabetic retinopathy of any severity should be referred promptly to a diabetic retinopathy specialist.
... Laser photocoagulation therapy to reduce the risk of vision loss is indicated for patients at high risk of proliferative diabetic retinopathy, clinically significant macular edema, and in some cases with severe nonproliferative diabetic retinopathy.
... The presence of retinopathy is not a contraindication to the appointment of aspirin for cardioprotection, since the use of this drug does not increase the risk of retinal hemorrhage.

Hypertension treatment
Non-drug methods of blood pressure correction
... Limiting the use of table salt to 3 g / day (do not salt food!)
... Weight loss (BMI<25 кг/м2) . снижение потребления алкоголя < 30 г/сут для мужчин и 15 г/сут для женщин (в пересчете на спирт)
... To give up smoking
... Aerobic physical activity for 30 - 40 minutes at least 4 times a week

Drug therapy for arterial hypertension
Table 20 The main groups of antihypertensive drugs (possibly used as monotherapy)

Group name	Name of drugs
ACE inhibitors	Enalapril 5 mg, 10 mg, 20 mg, Lisinopril 10 mg, 20 mg Perindopril 5 mg, 10 mg, Fozinopril 10 mg, 20 mg
ARB	Losartan 50 mg, 100 mg, Irbesartan 150 mg
Diuretics: .Thiazide and thiazide-like .Looped .Kalium-sparing (aldosterone antagonists)	Hydrochlorothiazide 25 mg, Furosemide 40 mg, Spironolactone 25 mg, 50 mg
Calcium channel blockers (CCBs) .Dihydropyridine (BKK-DHP) .Non-dihydropyridine (BCC-NDHP)	Nifedipine 10 mg, 20 mg, 40 mg Amlodipine 2.5 mg, 5 mg, 10 mg B erapamil, verapamil SR, diltiazem
β-blockers (BB) .Nonselective (β1, β2) .Cardioselective (β1) .Combined (β1, β2 and α1)	Propranolol Bisoprolol 2.5 mg, 5 mg, 10 mg, Nebivolol 5 mg Carvedilol

Table 21Additional groups of antihypertensive drugs (used in combination therapy)

Optimal combinations of antihypertensive drugs
... ACE inhibitors + thiazide,
... ACE inhibitors + thiazide-like diuretic,
... ACEI + BKK,
... ARB + \u200b\u200bthiazide,
... BRA + BKK,
... BKK + thiazide,
... BKK-DGP + BB

Table 22 Primary indications for the administration of various groups of antihypertensive drugs

ACEI - CHF - LV dysfunction - ischemic heart disease - Diabetic or non-diabetic nephropathy - LVH - Proteinuria / MAU - Atrial fibrillation	ARB - CHF - Transferred MI - Diabetic nephropathy - Proteinuria / MAU - LVH - Atrial fibrillation - Intolerance to ACE inhibitors	BB - ischemic heart disease - Transferred MI - CHF - Tachyarrhythmias - Glaucoma - Pregnancy	BKK -DGP - ISAG (elderly) - ischemic heart disease - LVH - Atherosclerosis of the carotid and coronary arteries - Pregnancy
BKK-NGDP - ischemic heart disease - Atherosclerosis of the carotid arteries - Supraventricular tachyarrhythmias	Thiazide diuretics - ISAG (elderly) - CHF	Diuretics (aldosterone antagonists) - CHF - Transferred MI	Loop diuretics - Terminal stage of chronic renal failure

Treatment of hypertension in children and adolescents:

Pharmacotherapy for high blood pressure (SBP or DBP consistently above the 95th percentile for a given age, gender, or height, or consistently\u003e 130/80 mmHg in adolescents) in addition to lifestyle interventions should be administered as early as possible after confirmation of the diagnosis ...

Consideration should be given to the feasibility of prescribing an ACE inhibitor as a starting drug for the treatment of hypertension.
... The target is constant blood pressure< 130/80 или ниже 90 перцентиля для данного возраста, пола или роста (из этих двух показателей выбирается более низкий).

Correction of dyslipidemia
Achieving compensation for carbohydrate metabolism helps to reduce the severity of dyslipidemia in patients with type 1 diabetes, which developed as a result of decompensation (mainly hypertriglyceridemia)

Dyslipidemia correction methods
... Non-drug correction:lifestyle modification with an increase in physical activity, a decrease in body weight (according to indications) and nutritional correction with a decrease in the consumption of saturated fats, trans fats and cholesterol.

... Medication correction.
Statins - first-line drugs to lower LDL-C levels. Indications for statins (always in addition to lifestyle interventions):

When the level of LDL cholesterol exceeds the target values;

Regardless of the initial level of LDL cholesterol in diabetic patients with diagnosed coronary artery disease.

If the goals are not achieved, despite the use of the maximum tolerated doses of statins, then a satisfactory result of therapy is a decrease in the concentration of LDL cholesterol by 30-40% from the initial one. If lipid targets are not achieved with adequate doses of statins, combination therapy with the addition of fibrates, ezetimibe, nicotinic acid, or bile acid sequestrants may be indicated.

Dyslipidemia in children and adolescents:
... In children over 2 years of age with a family history of aggravated (hypercholesterolemia [total cholesterol concentration\u003e 240 mg / dL] or the development of cardiovascular events before the age of 55 years) or unknown, the fasting lipid profile should be studied immediately after the diagnosis of diabetes mellitus (after reaching glycemic control). Unless a family history is present, the first lipid test should be done during adolescence (10 years or older). In all children diagnosed with diabetes during puberty or later, fasting lipid profile testing should be performed immediately after the diagnosis of diabetes mellitus (after reaching glycemic control).
... In case of deviations in indicators, it is recommended to determine the lipid profile annually. If the concentration indicators of LDL cholesterol correspond to the level of acceptable risk (< 100 мг/дл ), измерение концентрации липидов можно проводить каждые 5 лет.
Initial therapy is to optimize glucose control and nutritional therapy to limit saturated fat intake.
... Prescribing statins is indicated for patients over 10 years of age who, despite diet and an adequate lifestyle, have an LDL cholesterol index\u003e 160 mg / dL (4.1 mmol / L) or\u003e 130 mg / dL (3.4 mmol / L) in the presence of one or more risk factors for cardiovascular diseases.
... The target is LDL cholesterol< 100 мг/дл (2,6 ммоль/л).

Antiplatelet therapy
... Aspirin (75-162 mg / day) should be used as a primary prophylaxis in patients with type 1 diabetes and an increased cardiovascular risk, including patients over 40 years of age, as well as those with additional risk factors (family history of cardiovascular disease, hypertension, smoking , dyslipidemia, albuminuria).
... Aspirin (75-162 mg / day) should be used as a secondary prophylaxis in patients with diabetes and a history of cardiovascular disease.
... Clopidogrel should be used in patients with cardiovascular disease and aspirin intolerance.
... Combination therapy with acetylsalicylic acid (75-162 mg / day) and clopidogrel (75 mg / day) is advisable for a period of up to one year in patients after acute coronary syndrome.
... Prescribing aspirin is not recommended for persons under 30 years of age due to the lack of convincing evidence of the benefits of such treatment. Aspirin is contraindicated in patients under the age of 21 due to the risk of Reye's syndrome.

Celiac disease
... Patients with type 1 diabetes should be screened for celiac disease, including the determination of antibodies to tissue transglutaminase or endomysin (and confirmation of normal serum IgA concentrations is necessary) as soon as possible after the diagnosis of diabetes.
... If stunted growth, no weight gain, weight loss, or gastrointestinal symptoms appear, retests should be done.
... In children without celiac disease, consideration should be given to periodic re-examination.
... Children with positive antibody test results should be referred to a gastroenterologist for further evaluation.
... Children with confirmed celiac disease should be consulted by a nutritionist and given a gluten-free diet.

Hypothyroidism
... Children with type 1 diabetes should be tested for antibodies to thyroperoxidase and thyroglobulin immediately after diagnosis.

Determination of thyroid-stimulating hormone concentration should be performed after metabolic control has been optimized. At normal values, retests should be performed every 1-2 years. In addition, the patient should be scheduled for the aforementioned study if symptoms of thyroid dysfunction, thyomegaly, or abnormal growth rates appear. If thyroid-stimulating hormone values \u200b\u200bare outside the normal range, the free thyroxine (T4) content should be measured.

Outpatient drug treatment

Short-acting insulins

Ultra-short-acting insulin (analogs of human insulin)

Medium-acting insulins

Long-term, peakless insulin

List of additional medicines (less than 100% likely to be used):
Antihypertensive therapy:

Antilipidemic agents :

Diabetic neuropathy treatment :

Antianginal drugs
NSAIDs
Medicines affecting coagulation (Acetylsalicylic acid 75mg);

Inpatient drug treatment

Essential Medicines List (100% likely to be used):

Insulin therapy:

Short-acting insulins in vials (for ketoacidosis) and cartridges;

Ultra-short-acting insulins (analogs of human insulin: aspart, lispro, glulisine);

Medium-acting insulins in vials and cartridges;

Long-term, peakless insulin (detemir, glargine);

Sodium chloride 0.9% - 100ml, 200ml, 400ml, 500ml;

Dextrose 5% - 400ml;

Potassium chloride 40mg / ml - 10ml;

Hydroxyethyl starch 10% - 500ml (pentastarch);

For hypoglycemic coma:

Glucagon - 1mg;

Dextrose 40% - 20ml;

Osmotic diuretic (Mannitol 15% - 200ml).

List of additional medicines (less than 100% likely to be used):
Antibacterial therapy:

Penicillin series (amoxicillin + clavulanic acid 600mg);

Nitroimidazole derivatives (metronidazole 0.5% - 100ml);

Cephalosporins (cefazolin 1g; ceftriaxone 1000mg; cefepime 1000mg).
Antihypertensive therapy :
... ACE inhibitors (Enalapril 10 mg; Lisinopril 20 mg; Perindopril 10 mg; Fosinopril 20 mg; Captopril 25 mg);
... combination drugs (Ramipril + Amlodipine 10 mg / 5mg; Fosinopril + Hydrochlorothiazide 20mg / 12.5mg);
... ARB (Losartan 50 mg; Irbesartan 150 mg);
... diuretics (hydrochlorothiazide 25 mg; furosemide 40 mg, spironolactone 50 mg);
... Ca-channel blockers (Nifedipine 20 mg; Amlodipine 5 mg, 10 mg; Verapamil 80 mg);
... imidazonine receptor agonists (Moxonidine 0.4mg);
... beta-blockers (Bisoprolol 5 mg; Nebivolol 5 mg; Carvedilol 25 mg);
Antilipidemic agents :
... statins (Simvastatin 40mg; Rosuvastatin 20mg; Atorvastatin 10mg);
Treatment of painful forms of diabetic neuropathy:
... anticonvulsants (Pregabalin 75mg);
... antidepressants (Duloxetine 60mg; Amitriptyline 25mg);
... neurotropic B vitamins (Milgamma);
... opioid analgesics (Tramadol 50mg);
Treatment for diabetic neuropathy:
... derivatives of alpha-lipoic acid (thioctic acid fl 300mg / 12ml, table 600 mg;);
Diabetic Nephropathy Treatment :
... Epopoietin beta 2000 IU / 0.3 ml;
... Darbepopoietin alfa 30mcg;
... Sevelamer 800mg;
... Cinacalcet 30mg;
... Albumin 20%;

Antianginal drugs (Isosorbide mononitrate 40mg);
NSAIDs (Ketamine 500mg / 10ml; Diclofenac 75mg / 3ml or 75mg / 2ml);

Self-control of glycemia At least 4 times daily HbAlc Once every 3 months Biochemical blood test (total protein, bilirubin, AST, ALT, creatinine, GFR calculation, electrolytes potassium, sodium,) Once a year (if there are no changes) UAC Once a year OAM Once a year Determination of the ratio of albumin to creatinine in urine Once a year, 5 years after the diagnosis of type 1 diabetes {!LANG-7b1b02edeff528728dac888d9b9862eb!} {!LANG-796b418eeb4d6c42e9a50b18f1d1722e!}

{!LANG-34dfd592356e37858b32d1563cd5ec46!}

{!LANG-ad2fcb3b0dde61a133ae36077b9e0287!}{!LANG-0ea50f3fac297605dc269050c9499095!}

{!LANG-da564d5395ecf4c76467dae1d30b350f!}	{!LANG-56d3d0faccbc9e7e4ee189cba3048783!}
{!LANG-b39abf94b738b3145d243924dfd46fa3!}	{!LANG-a56c0d78704509401a2af760a254c39c!}
{!LANG-af1531866408fd60e7ba68f6594c9885!}	{!LANG-8ec05093bef41b513bcbf81e1911396d!}
{!LANG-bf80ecf56b45b6fe2fca357853167ec4!}	{!LANG-8ec05093bef41b513bcbf81e1911396d!}
{!LANG-7965f05ade7186b9ec3ce10f15afff8b!}	Once a year
{!LANG-3421454cb05677dadfc24e6810724e6f!}	Once a year
{!LANG-8eee9422f231c4562241ddeca83abb90!}	{!LANG-8ec05093bef41b513bcbf81e1911396d!}
{!LANG-d3465f3c38ebf13fdc8eaeba248396ba!} {!LANG-032a31b203daf4b98171e713a7de06a8!} {!LANG-e380a4d3e8b54c5e59d3b55211bf31af!}{!LANG-b1f577747372cf81e1c97f30fdf6130a!} Age groups {!LANG-74bba75e018e367ccc9d74fb47c97c1a!} {!LANG-d1fdc486c91777e008281fc52ad4c8a1!} HbA1c level,% Rational prerequisites Preschoolers (0-6 years old) 5,5-10,0 6,1-11,1 <8,5, но >7,5 {!LANG-1a7191af920d66f229c893c1d3c774c7!} Schoolchildren (6-12 years old) 5,0-10,0 5,6-10,0 <8,5 {!LANG-bcbbfffb71c76d9ce55a708e641ef5ce!} {!LANG-62b4095d7d15fabba0dedbee3d32f9c2!} 5,0-7,2 5,0-8,3 <7,5 {!LANG-ed70ba31f78b52fc997c96fe1456b965!} {!LANG-a100e31a2f3df9539744817fe632e6ca!} {!LANG-44b37040ebb6c47a224ae3814e5aab88!} {!LANG-b67b680440e1a397de3528ff48e3151e!} {!LANG-2193aff9119ef2a1ed5e2e38df2f7c67!} {!LANG-7e53a49f3f85cacd7ba2384ea8de8389!} SMG system{!LANG-ac49887b6f8b44bfaa635541552661fd!} {!LANG-a153528e18e777d02320cf8323e034fd!} {!LANG-d97fa0c8cfe95671ec66608baf63d463!} {!LANG-b1600d197a1ff99be95d1f8ae8217a9a!} {!LANG-d776a7402bd00515eb5dc5e49a7191a9!} {!LANG-69f5be3c4525723ae03f211b9b24aa35!} {!LANG-959c4fe0a37179f1be4a6764f03540c8!} {!LANG-286ef325a85d9d3767a5727a75899339!} {!LANG-a6493a9775ef1f9c9d6004b8331c31d9!} {!LANG-9d05955312d319383c2274aedc3d8ddc!} {!LANG-e344fab4149395b1eb0776a383e881a3!} {!LANG-c9439dfcb3905bd9453e34b08287e798!} {!LANG-81832706433782d8baca15bf91311a5b!} {!LANG-7992ca26103721199aec92b79dc55e93!} {!LANG-da36de92451b4b13128990943976864c!} {!LANG-2a91374dfa00fa51040ed6c988214423!} {!LANG-4723987b090afb9b0ad772f8ffc56f15!} {!LANG-cb79ae79d7526732b98b40cc4943e0ff!} {!LANG-7775dcd99ca95021bdbe3ff1dce0327b!} {!LANG-b7cc54cb019c2525317420737383f9b5!} {!LANG-b1c77e6480c6e900b3774fabb60a5bce!} {!LANG-1a17ed1b702cc78c6f8e7bfe68eab39f!} {!LANG-f7acc6d622b5d5d111e4b42c600b1612!} {!LANG-117ef970e11401512e6e07b9f4434012!}