Diabetes Mellitus

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Diabetes Mellitus
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What is diabetes mellitus?

• Metabolic derangement with hyperglycemia

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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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Glucose intolerance?

• Fasting plasma glucose gt110 mg/dL and lt126 mg/dL
  on two occasions
• Two hours glucose tolerance test with plasma
  glucose gt140 mg/dL and lt200mg/dL at 2 hour

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Other causes of hyperglycemia?

• Endocrine diseases
• Cushing's syndrome
• Acromegaly
• Pheochromocytoma
• Glucagonoma
• Hyperthyroidism
• Drug-induced
• Glucocorticoids
• Thiazides
• Nicotinic acid

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Type of diabetes?

• Type 1
• Insulin deficiency
• Early age onset
• Acute onset
• Ketosis
• Thin

• Type 2
• Insulin resistance
• Late onset
• Gradual, slow onset
• Usually non-ketotic
• Obese

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Diabetes Mellitus type 2
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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

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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

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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

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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

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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

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Symptoms

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

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Physical findings?

• Obesity (BMI gt26), especially centripetal obesity
  
• Eye signs - cataracts, microaneurysms,
  hemorrhages, hard exudates, soft exudates, new
  vessel formation, vitreous hemorrhage, macular
  degeneration

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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

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Associated metabolic disorders?

• Blood pressure 130/85
• Glucose intolerance with FBS 110 mg/dL
• Triglyceride gt150 mg/dL or HDL lt40 mg/dL in males
  and lt50 mg/dL in females
• Abdominal obesity with waist circumference gt102
  cm for males and gt89 cm for female

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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

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Tests

• Magnesium
• Homocysteine marker for cardiovascular risk
• Urine microalbumin and urinalysis
• EKG

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Treatments

• Control the hyperglycemia
• Management the complications

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Treatment options

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

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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

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Metformin

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

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Thiazolidinediones

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

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Arbacose

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

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Insulin

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

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Hemoglobin A1c goal?

• lt 7

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Aspirin

• Secondary prevention
• Primary prevention
• gt age 40 with cardiovascular risk factor(s)
• Not less age 21 because of increased risk of
  Reyes syndrome

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Hypertension goal?

• Keep blood pressure lt 130/80 mmHg

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Cholesterol goal?

• LDL lt 100 mg/dL

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Periodic exams?

• Annual dilated eye exam
• Annual monofilament test
• Annual urine microalbumin
• Annual serum creatinine
• Annual fasting lipid panel
• Hemoglobin A1c every 3 months

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Screening?

• gt age 45 and every 3 years
• Obesity with BMI gt27kg/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

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Hypoglycemia symptoms

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

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Hypoglycemia treatment

• Intravenous or intramuscular glucagon 1mg
• 20-50mL of 50 intravenous dextrose, followed by
  an infusion of 10-20 dextrose

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Neuropathy

• Peripheral neuropathy Elavil or Neurontin
• Erectile dysfunction Viagra

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Diabetic foot ulcer

• Control blood glucose
• Callus shaving
• Dressing changes
• Osteomyelitis leading to amputation