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Diabetes

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Symptoms of Diabetes. Increased thirst (polydypsia) Increased urination (polyuria) ... (with symptoms) 126 mg/dL. Diabetes. 140-199. 100-125 mg/dL. Impaired ... – PowerPoint PPT presentation

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Title: Diabetes


1
Diabetes
  • Michele Ritter, M.D.
  • Argy Resident February, 2007

2
Definition of Diabetes
  • A chronic metabolic condition characterized by
    elevated circulating glucose concentrations
    resulting from the insufficient supply or action
    of the hormone insulin.
  • Insulin
  • Stimulates glucose uptake by peripheral tissues
    (mainly skeletal muscles)
  • Suppresses endogenous glucose production (but
    hepatic glycogenlysis and gluconeogenesis)
  • Suppreses lipolysis in adipocytes and proteolysis
    in muscle.

3
Effects of Diabetes
  • Toxic effects of hyperglycemia on blood vessels
    results in chronic vascular complications.
  • Diabetic retinopathy
  • Diabetic neuropathy
  • Diabetic nephropathy
  • Poor wound healing
  • Cardiovascular disease

4
Symptoms of Diabetes
  • Increased thirst (polydypsia)
  • Increased urination (polyuria)
  • Weight loss despite increased food intake
  • Fatigue
  • Poor wound healing
  • Blurred vision
  • Nausea/vomiting (if in Diabetic ketoacidosis)

5
Diagnosis of Diabetes
  • American Diabetes Association and the World
    Health Organization

6
Diagnosis of Diabetes (cont.)
  • Fasting no food/drink for 8 hours
  • These tests should be repeated on additional
    visit to verify.
  • HgbA1C is NOT recommended for diagnosis!

7
Diabetes Type 1
  • Destruction of the pancreatic beta cells, leading
    to absolute insulin deficiency
  • Type 1A - due to autoimmune destruction of the
    pancreatic beta cells
  • Can check for islet-cell antibodies, anti-insulin
    antibodies, antibodies to glutamic acid
    dehydrogenase (anti-GAD)
  • Type 1B idiopathic
  • Have an absolute requirement for insulin, and
    will develop ketoacidosis if they dont receive
    it.
  • Adult-onset Type I Diabetes
  • Is actual cause of diabetes in 7.5-10 of
    previously diagnosed Type II diabetes in adults
  • Often found in non-obese adults
  • Diagnosed by positive auto-antibodies (especially
    anti-GAD)

8
Diabetes Type 2
  • The most common cause of Diabetes
  • Variable degrees of insulin resistance and
    deficiency
  • Typically present with hyperglycemia, and not
    ketoacidosis (though type II can go into diabetic
    ketoacidosis!)

9
Diabetes Other Causes
  • Gestational Diabetes
  • Placenta produces anti-insulin antibodies at
    times bodys own pancreatic function is unable to
    keep up with them
  • Occurs in 2.1 of women, usually in 2nd or 3rd
    trimester
  • Drug-Induced
  • Steroids!
  • HIV meds protease inhibitors, pentamadine
  • Atypical anti-psychotics (Clozapine)
  • Tacrolimus, Cyclosporine
  • Niacin
  • Hemochromatosis
  • Cushings Syndrome
  • Acromegaly
  • Chronic pancreatitis

10
Health Maintenance in Diabetic Patient
  • Question tobacco use Smoking cessation!
  • Diet and Exercise
  • Foot care
  • Avoid going barefoot, even in the home.
  • Test water temperature before stepping into a
    bath.
  • Trim toe nails to shape of the toe remove sharp
    edges with a nail file. Do not cut cuticles.
  • Wash and check feet daily.
  • Shoes should be snug but not tight and customized
    if feet are misshapen or have ulcers.
  • Socks should fit and be changed daily.
  • Home glucose log book

11
Health Maintenance in Diabetic Patient
  • Blood Pressure Check
  • Goal is 130/80
  • Dilated eye exam (ophthalmologist)
  • Type 1 within 3-5 years of diagnosis.
  • Type 2 shortly after diagnosis (within months)
  • Both should have subsequent annual eye exams.
  • Foot exam
  • Visual examination of feet at every visit
  • Comprehensive foot exam annually
  • Includes monofilament testing
  • Check skin for integrity, signs of erythema,
    calluses, ulcers

12
Monofilament foot exam
13
Routine Labs in Diabetic Patient
  • Chemistry
  • Annually
  • Watch for increase in creatinine
  • Microscopic urinalysis
  • Watch for protein (microalbuminuria)
  • Best way to catch early signs of nephropathy
  • Annually (or more frequently if abnormal)
  • TSH
  • At least once after diagnosis
  • Fasting lipid panel
  • Every five years, or more frequently if abnormal
  • Goal LDL is lt 100! (or less than lt70)

14
Routine labs in Diabetic Patients (cont.)
  • Hemoglobin A1c
  • Goal is HgbA1c lt7 (or in some cases lt 6.1)
  • Should be checked twice yearly in patients with
    good glycemic control, and quarterly in poorly
    controlled patients, or those changing therapies.

15
Treatment of Diabetes
  • Aspirin (75-325 mg)
  • Given to everyone 40 years, or to those with
    high risk for cardiovascular disease
  • Do not give to patients 21 because of risk of
    Reyes syndrome
  • Oral Therapies
  • Usually lower HgbA1c 1-2
  • Insulin
  • ACE inhibitor!

16
Oral Agents for Type 2 Diabetes
17
Insulin Therapy
  • Required for all Type I Diabetics, and many Type
    II Diabetics
  • Type I Require between 0.5 and 1.0 units of
    insulin per kilogram of bodyweight per day.
  • Types
  • Subcutaneous
  • Pump primarily in Type I diabetics
  • Inhaled (Exubera)
  • Approved by FDA in last year
  • Short-Acting (given before meals)
  • Need PFTs prior to starting

18
Insulin
  • Rapid-Acting
  • Lispro
  • Onset 10-15 min.
  • Peak 1-2 hours
  • Duration 3 5 hours
  • Aspart
  • Onset 10-15 min.
  • Peak 1-2 hours
  • Duration 3-5 hours
  • Short-acting Regular
  • Onset 0.5 1 hour
  • Peak 2-4 hours
  • Duration 4-8 hours

19
Insulin (cont.)
  • Intermediate-Acting
  • Neutral Protamine Hagedorn (NPH)
  • Onset 1-3 hours
  • Peak 4-10 hours
  • Duration 10-18 hours
  • Lente
  • Onset 2-4 hours
  • Peak 4-12 hours
  • Duration 12-20 hours

20
Insulin (cont.)
  • Long-acting
  • Insulin detemir
  • Onset 2-3 hours
  • Peak none
  • Duration up to 24 hours
  • Insulin glargine (lantus)
  • Onset 2-3 hours
  • Peak none
  • Duration 24 hours

21
Insulin
  • Pre-mixed
  • NPH/Regular 70/30
  • Onset 0.5 1 hour
  • Peak 2 10 hours
  • Duration 10 -18 hours
  • NPH/Regular 50/50
  • Onset 0.5 1 hour
  • Peak 2 -10 hours
  • Duration 10-18 hours
  • NPH/Aspart 70/30
  • Onset 10 -15 min.
  • Peak 1-3 hours
  • Duration 10-16 hours

22
Insulin the nitty-gritty
  • Good option
  • Long-acting insulin daily (Lantus!)
  • Short-acting insulin (Novolog) before each meal
    (pre-prandial) or with sliding scale insulin
    before each meal
  • Pre-meal insulin should be given 30 min. before
    eating
  • Use the am glucose to determine best dose of
    lantus (If running high, increase lantus if
    running low, decrease lantus)
  • Use sugars throughout the day to determine
    pre-meal/Sliding scale insulin
  • If sugars are increasing throughout day, and are
    really high by dinner time, increase pre-meal
    insulin doses.
  • If sugars keep getting low throughout day, could
    try decreasing pre-meal insulin.

23
What happens when patient admitted to hospital???
  • If only on oral hypoglycemics
  • Best to hold hypoglycemics (especially
    metformin!)
  • Place on Sliding scale insulin
  • If patient is insulin
  • Continue current insulin dose
  • Sliding scale insulin
  • If patient is NPO
  • Hold all oral hypoglycemics
  • Give ½ to ? of usual long-acting insulin.
  • Sliding scale insulin (with short-acting insulin)

24
ACE Inhibitors
  • Have been shown to be very beneficial in
    preventing nephropathy in patients with Diabetes.
  • Every diabetic patient with hypertension should
    be on ACE Inhibitor.

25
More extreme treatments for diabetes
  • Pancreas transplant
  • Usually always in conjunction with kidney
    transplant, or in patient who has already
    undergone kidney transplant.
  • Islet cell transplant
  • Showing a great deal of promise in clinical
    trials.

26
Case 1
  • A 52-year old female with a history of alcohol
    abuse presents to your clinic for a first time
    appointment for unexplained weight loss. The
    patient states that she has noticed about a 30
    pound weight loss over the last year,
    approximately 20 pounds of which were lost over
    the last 2 months, along with worsening fatigue.
    She states that 2 months ago she had an episode
    of bronchitis and went to an urgent care clinic
    where she was given a prednisone taper. She
    states that she eats a ton including an Ensure
    shake three times a day. She states that she
    also drinks water and ice tea all day long
    frequently has two glasses on her desk at any
    given time.

27
Case 1
  • PMH
  • h/o Alcohol abuse quit 9 months ago
  • h/o pancreatitis recurrent episodes over last
    several years has not had any problems for last
    year
  • PSH None
  • Allergies NKDA
  • Meds None
  • Social History
  • married history of alcohol abuse, as above 2
    packs/day tobacco for 40 years no IV drug use
    Currently unemployed

28
Case 1 (cont.)
  • Physical Exam
  • 136/72, 92 Ht 57 Wt 102 lb.
  • Gen Emaciated female alert and oriented, in
    NAD during the exam she asks if she can sneak
    out to use the bathroom
  • HEENT very dry mucous membranes
  • CV RRR
  • Resp LCTA bilaterally
  • Abd soft, nontender, NABS
  • Ext. no LE edema
  • Accucheck gt500!

29
Case 1
  • What would you do with this patient?
  • What labs would you check?
  • What consults might you make?
  • What medications would you start?

30
Case 2
  • A 45 year-old male with a history of hypertension
    and GERD presents to your office. He states that
    he is worried that he may be diabetic, since both
    his parents and his brother have diabetes. Hes
    not been to a doctor in a couple of years, but
    had previously been prescribed Hydrochlorothiazide
    for hypertension, and was taking OTC prilosec
    for his GERD.

31
Case 2
  • PMH Hypertension, GERD
  • PSH none
  • Allergies Sulfa (rash)
  • Outpatient meds OTC prilosec
  • Social History divorced, works as manager of
    bank no tobacco, 1-2 beers per week
  • ROS no fevers, no polyuria, no polydypsia, no
    N/V, no diarrhea/constipation

32
Case 2
  • Physical Exam
  • 168/92, 78, Ht 511 Wt 238
  • Gen Alert, oriented in NAD
  • CV RRR
  • Resp LCTA bilaterally
  • Abd soft, nontender, NABS
  • Ext. no LE edema

33
Case 2 - Labs
  • Sodium 140
  • Potassium 3.8
  • Chloride 102
  • CO2 26
  • BUN 17
  • Cr. 1.1
  • Glucose (fasting) 154
  • Total Cholesterol 208
  • HDL 43
  • LDL 148

34
Case 3
  • What additional testing would you like this
    patient to undergo?
  • What medications would you start at this time?
  • Would your management change if his fasting
    glucose was 124?

35
Final thoughts
  • Control of sugars is crucial in protecting
    diabetic patients from vascular damage.
  • Diabetes is now considered a coronary heart
    disease equivalent!
  • Smoking cessation!
  • Use ACE inhibitors in all diabetic patients with
    hypertension.
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