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DIABETES MELLITUS. THOMAS MILLIGAN, DO OSU-COM FAMILY MEDICINE. Introduction. Types of DM Diagnosis Management Follow-up Complications. TYPES. Type 1 Type 2. TYPE 1. Pathophysiology Diagnosis Management. DIAGNOSIS. Random BS of 200 plus symptoms Polyuria Polydipsia
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DIABETES MELLITUS THOMAS MILLIGAN, DO OSU-COM FAMILY MEDICINE
Introduction • Types of DM • Diagnosis • Management • Follow-up • Complications
TYPES • Type 1 • Type 2
TYPE 1 • Pathophysiology • Diagnosis • Management
DIAGNOSIS • Random BS of 200 plus symptoms • Polyuria • Polydipsia • Unexplained weight loss • Fasting BS 126 or Greater • NPO at Least 8 Hours • BS of 200, 2 Hours After 75g Glucose Challenge
MANAGEMENT • Diet • Decrease Glucose • Pt Must Not Skip Meals • Exercise • Insulin
PATHOPHYSIOLOGY • Immune related destruction of insulin producing cells • Loss of insulin • Insulin required to prevent DKA
INSULIN • Begin with 20 - 40 u day • 2/3 am, 1/3 pm • Am 2/3 inter, 1/3 regular • Pm 1/2 inter, 1/2 regular • Timing • Must be given with respect to meals
INSULIN • Adjustments • Average of 35 - 50 u day • 0.6 - 1.2 u/kg/day • Maintain FSBS 100 - 250 • Pt keeps log of FSBS to avoid hypoglycemia • Intermediate insulin • Change evening dose first • Beware of nocturnal hypoglycemia
INSULIN • Regular insulin • Guided by pre-prandial FSBS • Avoid regular insulin at bedtime • More diet and activity sensitive • Multiple Daily Injections (MDI) • Better control • Very compliant pts
INSULIN • ONSETPEAKDUR • LISPRO 15 - 30 m 1 - 3 h 3 - 6 h • REGULAR 15 - 60 m 2 - 6 h 4 - 12 h • NPH 1.5 - 4 h 6 - 16 h 14 -28 h • LENTE 1 - 4 h 6 - 16 h 14 -28 h
TYPE 2 • Pathophysiology • Diagnosis • Management
PATHOPHYSIOLOGY • Usually after age 30 • Usually obese • Insulin resistance • Insulin may be used, but not essential • Non ketotic hyperosmolar syndrome, not DKA
DIAGNOSIS • Random bs of 200 plus symptoms • Polyuria • Polydipsia • Unexplained weight loss • Fasting BS 126 or greater • NPO at least 8 hours • BS of 200, 2 hours after 75g challenge
MANAGEMENT • Diet • Exercise • Oral agents • Combination • Insulin
ORAL AGENTS • Sulfonylureas • Metformin • Troglitazone • Acarbose
SULFONYLUREAS • Diabinese, glucotrol, diabeta, micronase, prandin, amaryl • Increases insulin production • Hypoglycemia
METFORMIN • Glucophage • Decreases hepatic glucose production • No hypoglycemia
TROGLITAZONE • Rezulin • Increases peripheral glucose uptake • No hypoglycemia if used alone • Initial indication is for pts on insulin • Liver toxicity
ACARBOSE • Precose • Alpha-glucosidase inhibitor • Decreases glucose uptake in the gut • GI intolerance • No hypoglycemia
COMBINATION • Use one from each class • Reduce dose of other drugs by 1/2 if adding a sulfonylurea
INSULIN • Max out oral agents • Start with intermediate acting insulin • Eventually will use one modality
EVERY VISIT • FSBS • UA with microalbumin • Foot exam, including neuro
EVERY 3 MONTHS • HGB A1C
EVERY 6 MONTHS • Lipids • CHEM 8
YEARLY • Ophthomology consult • EKG
COMPLICATIONS • Retinopathy, neuropathy, cad, nephropathy, enteropathy, poor wound healing, impotence, depression • Hyperglycemia is better than no glycemia