diabetes mellitus what is diabetes mellitus? metabolic derangement with hyperglycemia
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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
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
Other causes of hyperglycemia? Endocrine diseases:
Cushing's syndrome Acromegaly Pheochromocytoma Glucagonoma Hyperthyroidism
Drug-induced: Glucocorticoids Thiazides Nicotinic acid
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
Diabetes Mellitus type 2
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
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
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
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
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
Symptoms 50% already develop complicationss Eye - visual deterioration, blurred
vision Neuropathy - numbness/paresthesias Angina Intermittent claudication Impotence
Physical findings? Obesity (BMI >26), especially
centripetal obesity Eye signs - cataracts,
microaneurysms, hemorrhages, hard exudates, soft exudates, new vessel formation, vitreous hemorrhage, macular degeneration
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
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
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
Tests Magnesium Homocysteine – marker for
cardiovascular risk Urine microalbumin and urinalysis EKG
Treatments Control the hyperglycemia Management the complications
Treatment options Diet Exercise Medications
Stimulating insulin secretion Block hepatic gluconeogenesis Increase insulin sensitivity Decrease GI absorption of glucose Insulin
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
Metformin Block hepatic gluconeogenesis Increase muscle sensitivity to
insulin Contraindications
Cr 1.5 in male and 1.4 in female CHF Contrast dye
Thiazolidinediones Rosiglitazone and pioglitazone Increase peripheral sensitivity to
insulin Monitor liver function tests to due
to increased risk of hepatitis
Arbacose Diarrhea Follow LFT periodically Contraindications
Hepatic or renal impairment IBD GI obstruction
Insulin Long acting for basal rate Short acting for meal May combine with oral medications
Hemoglobin A1c goal?
< 7%
Aspirin Secondary prevention Primary prevention
> age 40 with cardiovascular risk factor(s)
Not less age 21 because of increased risk of Reye’s syndrome
Hypertension goal?
Keep blood pressure < 130/80 mmHg
Cholesterol goal?
LDL < 100 mg/dL
Periodic exams? Annual dilated eye exam Annual monofilament test Annual urine microalbumin Annual serum creatinine Annual fasting lipid panel Hemoglobin A1c every 3 months
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
Hypoglycemia: symptoms Adrenergic symptoms: tachycardia,
palpitations, tremor, anxiety, and sweating
Neuroglycopenic: infaintness, feeling of hunger, headache, abnormal behavior, altered consciousness, and eventually coma
Hypoglycemia: treatment Intravenous or intramuscular
glucagon 1mg 20-50mL of 50% intravenous
dextrose, followed by an infusion of 10-20% dextrose
Neuropathy Peripheral neuropathy – Elavil or
Neurontin Erectile dysfunction – Viagra
Diabetic foot ulcer Control blood glucose Callus – shaving Dressing changes Osteomyelitis leading to
amputation