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Overview of Diabetes Mellitus

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Foot ulcers/gangrene. Angina/MI/CVA. Annual Assessment. Osmotic symptoms. Hypoglycaemia ... Gangrene. Doppler Studies. Duplex Scanning. Angiography. Angioplasty ... – PowerPoint PPT presentation

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Title: Overview of Diabetes Mellitus


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

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

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
Diagnosis
  • Fasting blood glucose gt 7mmol/l
  • Random blood glucose gt11.1mmol/l
  • 75g OGTT

6
75g OGTT
  • Diabetic FBGgt7 2h gt11.1 mmol/l
  • IGT FBG lt7 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
Type 1 diabetesType 2 diabetes
  • Juvenille
  • Abrupt onset
  • Family history
  • Autoimmune
  • Ketones
  • Total insulin def,
  • Islet cell AB pos
  • HLA DR3 DR4
  • Insulin dependent
  • Older age
  • Slow onset
  • Family history
  • Not autoimmune
  • No ketones
  • Partial Insulin def/Resistance
  • Insulin requiring
  • Diet/OHA

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

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

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

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

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

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

15
Treat to Target
  • HbA1C lt 7
  • BP lt 140/80
  • Cholesterol lt5 mmol/l
  • HDL-C gt1mmol/l
  • LDL-C lt 2mmol/l
  • Triglycerides lt1.5mmol/l

16
Hypoglycaemia lt2.5mmol/l
  • Autonomic
  • Neuroglycopenic
  • LOC
  • Cerebral Oedema
  • Too much insulin
  • Food omission
  • Sulphonylureas
  • Renal impairement

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

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

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

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

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

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

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

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

25
Diabetic Foot
  • Neuropathy
  • PVD
  • Charcot Arthropathy
  • Ulceration
  • MRI
  • Angiography

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

27
Nephropathy
  • Diabetic glomerulosclerosis
  • Microalbuminuria lt300mg/l
  • Proteinuria gt300mg/l
  • Nephrotic gt3g/l
  • Abnormal creatinine
  • Glycaemic control
  • BP control
  • CAPD
  • Transplantation

28
Screening
  • BMIgt30
  • Age gt50
  • Ethnic minorities
  • Family history
  • GDM
  • Urinalysis
  • FBG
  • Random glucose
  • OGTT
  • Cost/benefit analysis

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 2002359 2072-2077.
  • JAMA 2003290 486-494
  • TRIPOD Study Pioglitazone

30
Literature
  • DCCT Trial(Type1) Diabetes 199645 1289-1298
    NEJM 1993329977
  • UKPDS study (Type 2) Lancet 1998352837-853
  • DIGAMI (CCU)
  • BMJ 19973141512-1515
  • Lancet 2002259
  • Lancet 2000 355 733-777
  • ICU patients NEJM 20013451359-1367
  • WOSCOPS 4S ASCOT Lancet 20033611149-1158
    (Statin)
  • HOPE (ACE-I) NEJM 2000342145-153
  • ALL-HAT (ACE-I) JAMA 20022882981-2997
  • LIFE SCOPE (ARB)
  • CARDS Study (Lancet August 2004)
  • DIGAMI 2 study (in press).
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