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DIABETES MELLITUS

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

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  1. DIABETES MELLITUS THOMAS MILLIGAN, DO OSU-COM FAMILY MEDICINE

  2. Introduction • Types of DM • Diagnosis • Management • Follow-up • Complications

  3. TYPES • Type 1 • Type 2

  4. TYPE 1 • Pathophysiology • Diagnosis • Management

  5. 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

  6. MANAGEMENT • Diet • Decrease Glucose • Pt Must Not Skip Meals • Exercise • Insulin

  7. PATHOPHYSIOLOGY • Immune related destruction of insulin producing cells • Loss of insulin • Insulin required to prevent DKA

  8. 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

  9. 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

  10. 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

  11. 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

  12. TYPE 2 • Pathophysiology • Diagnosis • Management

  13. PATHOPHYSIOLOGY • Usually after age 30 • Usually obese • Insulin resistance • Insulin may be used, but not essential • Non ketotic hyperosmolar syndrome, not DKA

  14. 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

  15. MANAGEMENT • Diet • Exercise • Oral agents • Combination • Insulin

  16. ORAL AGENTS • Sulfonylureas • Metformin • Troglitazone • Acarbose

  17. SULFONYLUREAS • Diabinese, glucotrol, diabeta, micronase, prandin, amaryl • Increases insulin production • Hypoglycemia

  18. METFORMIN • Glucophage • Decreases hepatic glucose production • No hypoglycemia

  19. TROGLITAZONE • Rezulin • Increases peripheral glucose uptake • No hypoglycemia if used alone • Initial indication is for pts on insulin • Liver toxicity

  20. ACARBOSE • Precose • Alpha-glucosidase inhibitor • Decreases glucose uptake in the gut • GI intolerance • No hypoglycemia

  21. COMBINATION • Use one from each class • Reduce dose of other drugs by 1/2 if adding a sulfonylurea

  22. INSULIN • Max out oral agents • Start with intermediate acting insulin • Eventually will use one modality

  23. EVERY VISIT • FSBS • UA with microalbumin • Foot exam, including neuro

  24. EVERY 3 MONTHS • HGB A1C

  25. EVERY 6 MONTHS • Lipids • CHEM 8

  26. YEARLY • Ophthomology consult • EKG

  27. COMPLICATIONS • Retinopathy, neuropathy, cad, nephropathy, enteropathy, poor wound healing, impotence, depression • Hyperglycemia is better than no glycemia

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