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Overview of Diabetes Mellitus

Overview of Diabetes Mellitus. Dr F Dunne Dept of Medicine. Definition Diagnosis Classification Symptoms Annual Assessment Treatment options. Metabolic complications Macrovascular complications Microvascular complications. Layout. Definition.

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Overview of Diabetes Mellitus

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  1. Overview of Diabetes Mellitus Dr F Dunne Dept of Medicine

  2. Definition Diagnosis Classification Symptoms Annual Assessment Treatment options Metabolic complications Macrovascular complications Microvascular complications Layout

  3. Definition • A syndrome caused by a decrease or total lack of insulin or diminished effectiveness of circulating insulin (insulin resistance) • Characterised by hyperglycaemia

  4. Insulin • Enhances peripheral glucose uptake • Inhibits breakdown of liver glycogen • Enhances storage of glucose as glycogen • Increases protein synthesis • Increases triglyceride storage

  5. Fasting blood glucose > 7mmol/l Random blood glucose >11.1mmol/l 75g OGTT Diagnosis

  6. 75g OGTT • Diabetic: FBG>7; 2h >11.1 mmol/l • IGT : FBG <7; 2h 7.8-11.1 mmol/l • IFG: FBG 6.1-6.9 mmol/l

  7. Classification • Type 1 diabetes • Type 2 diabetes • Secondary diabetes

  8. Older age Slow onset Family history Not autoimmune No ketones Partial Insulin def/Resistance Insulin requiring Diet/OHA Type 1 diabetes;Type 2 diabetes • Juvenille • Abrupt onset • Family history • Autoimmune • Ketones • Total insulin def, • Islet cell AB pos • HLA DR3 DR4 • Insulin dependent

  9. Steroids Thiazide Diuretics Drugs for HIV Pancreatectomy Acute pancreatitis Chronic Pancreatitis Haemachromatosis Cystic Fibrosis Cushings Disease Acromegaly MODY DIDMOAD Secondary Diabetes

  10. Polyuria Polydypsia Weight loss Lethargy Tiredness Blurred Vision Boils/abscesses Pruritus Vulvae DKA Retinopathy Nephropathy Neuropathy Foot ulcers/gangrene Angina/MI/CVA Symptoms

  11. Osmotic symptoms Hypoglycaemia Injection sites Treatment Diabetes nurse specialist Dietitian Blood pressure VAs Fundoscopy Pulses/CFT Neurology of Legs Urinalysis HbA1C Lipids Renal function Annual Assessment

  12. Treatment • Relief of osmotic symptoms • Avoid complications • Choice of treatments dependent on type, age, family support etc.

  13. Rapid acting Insulin Long acting Insulin Mixed Insulins Short acting analogues Long acting analogues Treatments of Glucose • Diet • Metformin • Sulphonylureas • Acarbose • Thiazolidinediones • Netaglinide/Repag.

  14. Other treatments • Anti-hypertensives • Statins/fibrates • Aspirin • ACE inhibitors • ARBs

  15. Treat to Target • HbA1C < 7% • BP < 140/80 • Cholesterol <5 mmol/l • HDL-C >1mmol/l • LDL-C < 2mmol/l • Triglycerides <1.5mmol/l

  16. Too much insulin Food omission Sulphonylureas Renal impairement Hypoglycaemia <2.5mmol/l • Autonomic • Neuroglycopenic • LOC • Cerebral Oedema

  17. Treatment • Food • Dextrose tablets • Hypostop • Glucose infusion • Glucagon

  18. Infection Omits insulin Dehydration Ketotic Hyperventilating Hypotensive Tachycardia Coma Glucose/ketones/ acidotic on ABG IV Fluids Insulin Potassium Antibiotics DKA – Serious/Life threatening

  19. Type 2 Unwell for days Not acidotic No ketones Very high glucose Risk of clotting Fluids Insulin Potassium Heparin HONK

  20. Peripheral Neurop Femoral Amyotrophy Mononeuritis multiplex Autonomic Neuropathy Postural hypotension Diarrhoea Impotence Atonic bladder Sweating Loss of hypo. awarenes Neuropathy

  21. PVD CVD CAD Diabetes Hypertension Proteinuria Lipids Cigarettes Obesity Vascular Disease

  22. Intermittent Claudication Cold Legs Pulseless Leg Foot Ulcers Gangrene Doppler Studies Duplex Scanning Angiography Angioplasty Treat risk factors PVD

  23. TIAs CVAs Dementia CT scan Carotid Dopplers Treat risk factors Carotid bypass surgery CVD

  24. Angina MI Silent infarct CCF ECG Cardiac enzymes Troponin I Exercise stress test Echocardiography Angiography Angioplasty/CABG CAD

  25. Neuropathy PVD Charcot Arthropathy Ulceration MRI Angiography Diabetic Foot

  26. Background DR Pre-proliferative DR Proliferative DR Maculopathy Fluroscein angiography Laser Blood Pressure Lipids Glucose Retinopathy

  27. Diabetic glomerulosclerosis Microalbuminuria <300mg/l Proteinuria >300mg/l Nephrotic >3g/l Abnormal creatinine Glycaemic control BP control CAPD Transplantation Nephropathy

  28. BMI>30 Age >50 Ethnic minorities Family history GDM Urinalysis FBG Random glucose OGTT Cost/benefit analysis Screening

  29. Diabetes is preventable by life style modification • Da Quing (Chinnese)31-46% reduction • Finnish (Europeans)58% reduction • DPP (North Americans) 58% reduction • STOP –NIDDM Trial Acarbose Lancet 2002;359: 2072-2077. JAMA 2003;290: 486-494 • TRIPOD Study Pioglitazone

  30. DCCT Trial(Type1) Diabetes 1996;45: 1289-1298 NEJM 1993;329;977 UKPDS study (Type 2) Lancet 1998;352:837-853 DIGAMI (CCU) BMJ 1997;314:1512-1515 Lancet 2002:259; Lancet 2000; 355: 733-777 ICU patients NEJM 2001;345:1359-1367 WOSCOPS; 4S; ASCOT Lancet 2003;361;1149-1158 (Statin) HOPE (ACE-I) NEJM 2000;342:145-153 ALL-HAT (ACE-I) JAMA 2002;288:2981-2997 LIFE SCOPE (ARB) CARDS Study (Lancet August 2004) DIGAMI 2 study (in press). Literature

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