Diabetes Mellitus

1. Diabetes Mellitus Epidemiology/Risk Factors

2. Epidemiology • It’s estimated that there were 30 million cases in 1985 to 285 million in 2010. • International Diabetes Federation projects that 438 million individuals will have diabetes by the year 2030 • Prevalence of Type 1 and Type 2 are both increasing but Type 2 is increasing at a faster rate due to: • increasing numbers of obesity • Reduced activity levels • Aging population

4. Statistics • Centers for Disease Control and Prevention (CDC) estimated that 25.8 million personsor 8.3% of the population had diabetes • ***27% of the individuals with diabetes were undiagnosed). • 1.6 million individuals (>20 years) were newly diagnosed with diabetes in 2010. • In 2007, DM ,7th leading cause of death • 5th leading cause of death worldwide

5. Statistics • 2010, the prevalence of DM in the United States • 0.2% in individuals aged <20 years • 11.3% in individuals aged >20 years • >65 yo, the prevalence of DM was 26.9%. • Similar prevalence both genders: (of individuals aged >20 years) • M 11.8% • F 10.8% By 2030 the greatest number of individuals with diabetes will be aged 45–64 years, worldwide!

6. Risk Factors Type 1 • Largely unknown; microbial, chemical, dietary, other • Human leukocyte antigen associations • Higher incidence of human leukocyte antigen (HLA) types DR3, DR4 • Usually <30 yr, particularly childhood and adolescence, but any age • Associated diseases: Autoimmune; Graves’ disease, Hashimoto’s thyroiditis, vitiligo, Addison’s disease, pernicious anemia

7. Risk Factors Type 2 • Age( Usually >40 yo, but any age • obesity (central) • sedentary lifestyle • previous gestational diabetes • Diet: high carbohydrate content in food • Hereditary factors: 90% concordance rate in identical twins

8. Diabetes Mellitus Pathophysiology

9. Pancreas • Islets of Langerhans - 4 types of hormone secreting cells • alpha cells - secrete glucagon • beta cells - secrete insulin • delta cells - gastrin • F cells - secrete pancreatic polypeptide

10. Diabetes Type 1 • Genetic susceptibility • HLA region on chromosome 6 • Autoimmunity • Autoantibodies that destroy islet/beta cells • Environmental factors • Viruses • Infecting or destroying beta cells • Triggering an autoimmune reaction against the beta cells

11. Diabetes Type 2 • Genetic susceptibility • No autoimmune mechanisms • Insulin resistance • Impaired insulin secretion

12. Diabetes Mellitus PMH/Family/Social History

13. Past Medical History • PMH • Systemic hypertension • HDL < 35 • Severe Obesity • Visceral fat along the waist • Triglycerides > 250 • History of cardiovascular disease *All reasons to start screening for diabetes

14. Past Medical History • Diabetes secondary to the following: • Hormonal excess: Cushing’s syndrome, acromegaly • Drugs: glucocorticoids, diuretics, BC pills • Pancreatic disease: Pancreatitis, Pancreatectomy • Gestational Diabetes (GDM)

15. Family History • 1st degree relative with Diabetes • Mother w/ diabetes: 3% chance of developing • Father w/ diabetes: 6% chance of developing • Siblings with diabetes: 6% if 1 gene is shared, 12-25% if 2 genes are shared. • Identical Twins: If 1 twin has type 1, there is a 25-50% chance the other will develop it. • High-risk ethnic population

16. Social History • Type 1: • Environmental factors such as viral infections. (coxsackie virus, mumps virus) • Type 2: • Obesity • Sedentary lifestyle • High carbohydrate intake

17. Diabetes Mellitus Patient Symptoms/ PE Signs

18. Type 1 Diabetes Symptoms • Polyuria • Polydyspia • polyphagia • Weight loss • Weakness/fatique • Noctural enuresis

19. Type 1 Diabetes PE Signs • Young • Lean/wasted • Dehydration- loss of turgor • Insulin decreased to absent • Increased glucagon in blood • Ketoacids in urine

20. Type 2 Diabetes Symptoms • Asymptomatic initially • Polyuria (less than type 1) • Recurrent blurred vision • Peripheral neuropathy • Weakness and fatigue (less than Type 1) • Chronic skin infections

21. Type 2 Diabetes PE Signs • Adults (not always) • Obese or overweight • Localization of fat deposits around abdomen, chest, neck • High waist circumference • Hyperpigmentation of back of neck, axilla and groin • Increased glucagon and insulin in blood

22. Diabetes Mellitus Labs/Differential Diagnoses/ Complications

23. Labs • Fasting Plasma Glucose • Normal: <100mg/dL • Prediabetic: 100-125 mg/dl • Hemoglobin A1C • Normal 5.6% • Impaired 5.7-6.4% • Oral Glucose Tolerance Test • Normal 140 mg/dL • Prediabetic 140-199 mg/dl

24. Labs • Lipid Profile • BUN (blood urea nitrogen) • Creatinine • Urinalysis • Microalbumin

25. DDX • Cushing Syndrome • Acromegally • Metabolic Acidosis • Renal Glycosuria • Drug-induced glucose intolerance • Pancreatic insufficiency

26. Complications • Ketoacidosis • Infections • Nephropathy • Retinopathy • Neuropathy • Diabetic Feet • Cardiovascular Disease • Hyperlipidemia

27. Complications • Diabetic Ketoacidosis (DKA) • Usually in insulin-dependent DM • Not enough insulin to meet body’s needs • Ketogenesis • metabolic acidosis • Osmotic diuresis (increase in urine volume) • dehydration

28. Complications • Greater risk for Infections • CAP • Influenza • Cholecystitis • UTI • Fungal infections (candidiasis, eye, skin)

29. Complications • Nephropathy • Higher incidence in Type 1 • higher prevalence in Type 2 • Most common cause of ESRD *Risk factors: • Poor glycemic control • Smoking • HTN

30. Complications • Retinopathy • 20% Type 2 show signs at diagnosis • Small retinal hemorrhages • Extensive growth of new vessels (progressive) • Retina • Vitreous humor • Increased risk with higher HgbA1C and with longer duration of DM

31. Complications • Neuropathy (Peripheral) • Loss of sensation/pain in extremities (feet) • Begins in toes and eventually legs, fingers, arms • Major cause of foot problems in these pts

32. Complications • Diabetic Feet • Leading NON-traumatic cause of foot amputation in US due to: • Neuropathy • Vasculopathy • Ulcers • 15% of diabetics have foot ulcers • Of those, 20% of ulcers will lead to an amputation

33. Complications • Hyperlipidemia • Type 2 pts have TRIAD: • Increased LDL • Increased triglycerides • Decreased HDL

34. Complications • Cardiovascular Disease • Leading cause of death in DM pts • Men have 2x risk for MI • Women 4-5x risk for MI • Increased incidence of plaque rupture, thrombosis, in-hospital mortality

35. Diabetes Mellitus Treatment

36. Oral Medications • Metformin (Glucophage)- typically twice a day  side effect diarrhea • Metformin ER- one daily • Sulfonylureas (Glimepiride, Glipizide, Glyburide)- 1-2x daily  side effect hypoglycemia • Prandin, Starlix- taken with meals • Actos- one daily • Januvia, Onglyza, Tradjenta- one daily • Bile acid sequestrants- Welchol • Combination pills

37. Insulin • Fast Acting: taken before meals (0-15 mins) set dose before meals or sliding scale • Novolog, Humalog, Apidra • Long Acting: taken in am/ at night or both • Lantus, Levemir • Mixes: Both fast acting and long acting agent--taken typically before 2 largest meals (breakfast and dinner) • Humalog Mix 75/25, Novolog Mix 70/30, Humalog Mix 50/50

38. Injectable Hormones • Victoza- once daily • Byetta- twice daily • Bydureon- new similar to Byetta once a week • Symlin- three times daily • Side effects of all include nausea

39. Insulin Pumps • 24 hour insulin- basal rate • Bolus- for food intake • Medtronic • Animas • One Touch Ping • Omni-Pod- no tubing CGMS- Continuous Glucose Monitoring System: measures BG every 5 min.

40. Blood Glucose Monitoring • Monitor blood glucose- number of times daily varies depending on patient

41. Patient Education • Healthy diet • Exercise • Foot care- diabetic shoes • Annual Eye exam- retinopathy • Stress Testing, EKG, ECHO • Ideal blood glucose range • Treatment of low and high blood glucose • Use of Glucagon- for severe hypoglycemia

42. Sources • Current Medical Dx & Tx • Ferri’s Clinical Advisor • UpToDate • Harrison’s Principles of Internal Med.