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Diabetes Mellitus

Diabetes Mellitus. What is diabetes mellitus?. Metabolic derangement with hyperglycemia. How DM is diagnosed?. Fasting plasma glucose  126 mg/dL on two occasions Random plasma glucose  200 mg/dL with symptoms Two hours glucose tolerance test with plasma glucose  200 mg/dL at 2 hour.

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Diabetes Mellitus

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  1. Diabetes Mellitus

  2. What is diabetes mellitus? Metabolic derangement with hyperglycemia

  3. How DM is diagnosed? • Fasting plasma glucose  126 mg/dL on two occasions • Random plasma glucose  200 mg/dL with symptoms • Two hours glucose tolerance test with plasma glucose  200 mg/dL at 2 hour

  4. Glucose intolerance? • Fasting plasma glucose >110 mg/dL and <126 mg/dL on two occasions • Two hours glucose tolerance test with plasma glucose >140 mg/dL and <200mg/dL at 2 hour

  5. Other causes of hyperglycemia? • Endocrine diseases: • Cushing's syndrome • Acromegaly • Pheochromocytoma • Glucagonoma • Hyperthyroidism • Drug-induced: • Glucocorticoids • Thiazides • Nicotinic acid

  6. Type 1 Insulin deficiency Early age onset Acute onset Ketosis Thin Type 2 Insulin resistance Late onset Gradual, slow onset Usually non-ketotic Obese Type of diabetes?

  7. Diabetes Mellitus type 2

  8. Epidemiology • Distribution: 75-90% of diabetes mellitus • Incidence: • 3/1000 new cases in Caucasian populations per year (probably an underestimate) • May be 2-4 times higher according to some reporting agencies • Prevalence • Affects 50-70/1000 people in the US • A further 27/1000 have undiagnosed diabetes on the basis of fasting glucose

  9. Predisposing factors? • Age: • Prevalence increases with age • Diagnosed at over 40, although the group with the largest and fastest increase in incidence is under age 25 • Prior history of gestational diabetes • Obesity

  10. Predisposing factors • Race • Prevalence is increased in: • African-Americans • Hispanic-Americans • Native Americans • Asian-Americans • Pacific Islanders • Pima Indians • Socioeconomic status l • Lower socioeconomic groups

  11. Predisposing factors • Genetics • Positive family history in 30% of cases • Concordance rates of approx. 90% in identical twins • One first-degree relative doubles the relative risk and two first-degree relatives increases the risk 4-fold • Not associated with specific HLA genes (unlike type 1 diabetes) • Polymorphisms have been identified within specific ethnic populations Polymorphisms have been identified within specific ethnic populations

  12. Symptoms? • 40% are asymptomatic at diagnosis • Lethargy • Malaise • Blurred vision • Polyuria • Polydipsia • Frequent infections, e.g. candidiasis, balanitis, intertrigo, boils, cellulitis, urinary tract infections, vaginal yeast infections; poor wound healing

  13. Symptoms • 50% already develop complicationss • Eye - visual deterioration, blurred vision • Neuropathy - numbness/paresthesias • Angina • Intermittent claudication • Impotence

  14. Physical findings? • Obesity (BMI >26), especially centripetal obesity • Eye signs - cataracts, microaneurysms, hemorrhages, hard exudates, soft exudates, new vessel formation, vitreous hemorrhage, macular degeneration

  15. Physical findings • Cardiac: congestive heart failure from prior MI • Foot - decreased peripheral pulses, decreased protective sensation, absent ankle-jerk reflex, ulcers • Polyneuropathy, mononeuropathy (less common than polyneuropathy) • Associated hypertension

  16. Associated metabolic disorders? • Blood pressure ≥ 130/85 • Glucose intolerance with FBS ≥ 110 mg/dL • Triglyceride >150 mg/dL or HDL <40 mg/dL in males and <50 mg/dL in females • Abdominal obesity with waist circumference >102 cm for males and >89 cm for female

  17. Tests? • Fasting plasma glucose • Hemoglobin A1c • Elevated in uncontrolled diabetes, lead toxicity, iron-deficiency anemia, hypertriglyceridemia • Decreased in hemolytic anemias, chronic renal failure • Fasting lipid panel • Bun/Cr

  18. Tests • Magnesium • Homocysteine – marker for cardiovascular risk • Urine microalbumin and urinalysis • EKG

  19. Treatments • Control the hyperglycemia • Management the complications

  20. Treatment options • Diet • Exercise • Medications • Stimulating insulin secretion • Block hepatic gluconeogenesis • Increase insulin sensitivity • Decrease GI absorption of glucose • Insulin

  21. Insulin secretagogues • Sulonylureas • First-generation – chlorpropamide, tolazamide, tolbutamide • Second-generation – • glyburide and glipizide • Glimepiride – enhance peripheral insulin sensitivity • Contraindicated in severe hepatic or renal disease • Meglitinides • Repaglinide, nateglinide • Attenuated without exogenous glucose • Contraindication in hepatic impairment

  22. Metformin • Block hepatic gluconeogenesis • Increase muscle sensitivity to insulin • Contraindications • Cr  1.5 in male and 1.4 in female • CHF • Contrast dye

  23. Thiazolidinediones • Rosiglitazone and pioglitazone • Increase peripheral sensitivity to insulin • Monitor liver function tests to due to increased risk of hepatitis

  24. Arbacose • Diarrhea • Follow LFT periodically • Contraindications • Hepatic or renal impairment • IBD • GI obstruction

  25. Insulin • Long acting for basal rate • Short acting for meal • May combine with oral medications

  26. Hemoglobin A1c goal? < 7%

  27. Aspirin • Secondary prevention • Primary prevention • > age 40 with cardiovascular risk factor(s) • Not less age 21 because of increased risk of Reye’s syndrome

  28. Hypertension goal? Keep blood pressure < 130/80 mmHg

  29. Cholesterol goal? LDL < 100 mg/dL

  30. Periodic exams? • Annual dilated eye exam • Annual monofilament test • Annual urine microalbumin • Annual serum creatinine • Annual fasting lipid panel • Hemoglobin A1c every 3 months

  31. Screening? • > age 45 and every 3 years • Obesity with BMI >27kg/m2 • First relative with diabetes • High-risk ethnic group • GDM or macrosomia baby • HDL 35 mg/dL and TG 250 mg/dL • Disorder associated with insulin resistance such as PCO

  32. Hypoglycemia: symptoms • Adrenergic symptoms: tachycardia, palpitations, tremor, anxiety, and sweating • Neuroglycopenic: infaintness, feeling of hunger, headache, abnormal behavior, altered consciousness, and eventually coma

  33. Hypoglycemia: treatment • Intravenous or intramuscular glucagon 1mg • 20-50mL of 50% intravenous dextrose, followed by an infusion of 10-20% dextrose

  34. Neuropathy • Peripheral neuropathy – Elavil or Neurontin • Erectile dysfunction – Viagra

  35. Diabetic foot ulcer • Control blood glucose • Callus – shaving • Dressing changes • Osteomyelitis leading to amputation

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