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