Prince Sattam Bin AbdulAziz University College Of Pharmacy

Professor Mohammad Abd- elmotaal Mohammad Ruhal Ain,

R Ph, PGDPRA, M Pharm

Diabetes Mellitus Cases

Email :- m,alain@sau.edu.sa

R.P. is a 43-year-old African American woman visiting the drop-in clinic to obtain a routine physical examination for her new job. Her past medical history is significant for GDM. She was told during her two pregnancies (last child born 3 years ago) that she had “borderline diabetes,” which resolved each time after giving birth.

Her family history is significant for type 2 diabetes (mother, maternal grandmother, older first cousin), hypertension, and CVD.

She denies tobacco or alcohol use. She states she tries to walk 15 minutes twice a week.

Case 1

Physical examination is significant for moderate central obesity (5 feet 4 inches; 160 lbs; BMI, 30.2 kg/m2) and BP 145/85 mmHg. R.P.

denies any symptoms of polyphagia, polyuria, or lethargy.

Upon checking her electronic medical record, she has documented hypertension and an FPG value of 119 mg/dL, measured 2 months prior.

BMI; below 18.5 underweight .BMI; 18.5 to 24.9 healthy .BMI of 25 to 29.9 overweight .BMI; 30 or higher obese.

What features of R.P.’s history and examination are consistent with an increased risk of developing type 2 diabetes?

1 -Age2 -Ethnicity

3 -Weight4 -Family history of

diabetes5 -History of GDM

6 -Documented IFG.7 -Hypertension

Increased risk of developing type 2 diabetes?

2 .The physician orders another FPG for R.P., which comes back at 122 mg/dL. How should R.P. be managed at this time?A. Patient education ..

………………………………………………………….... diabetes .

B. lifestyle modifications (MNT, physical activity) .………

for

About risk factors of developing

lose weight,improve her cardiovascular healthdecrease her risk for developing type 2 diabetes.

Medical Nutrition Therapy= MNT

Treatment There are three major components to the treatment of diabetes :

1 -Diet

2 -Drugs (insulin and oral hypoglycemic agents, and other

antihyperglycemic agents)

3 -Exercise .

Q. What are the three major components to the

treatment diabetes ?

Q. How to manage patient with increased risk of

developing D.M?

Q. Life style modification benefits?

A.H., a slender, 18-year-old woman who was recently discharged from the hospital for severe dehydration and mild ketoacidosis is referred to the Diabetes Clinic (no records available).

A fasting and a random plasma glucose ordered subsequently were 190 mg/dL (normal, 70–100) and 250mg/dL (normal, 140 to<200).

4weeks before she was hospitalized, A.H. she remembers that she had symptoms of polydipsia, nocturia (six times a night), fatigue, and a 12-lb weight loss over this period, which she attributed to the anxiety associated with her move away from home and adjustment to her new environment.

Case 2

Medical history I. Recurrent upper respiratory infections II. Three cases of vaginal moniliasis over the

past 6 months.

Family history is negative for diabetes, and she takes no medications.

Physical examination is within normal limits. (weight 50 kg and is 5 feet 4 inches tall)

Laboratory results are as follows: FPG, 280 mg/dL (normal, <100); HbA1c, 14%(normal, 4%–6%); and trace urine ketones as measured by Keto-Diastix (normal, negative).

A,H diagnosis is consistent with ?

A. D.M type IB. D.M type 2 C. Impaired fasting blood glucose

(IFG)D. None of the above

Define Diabetes ?

Compare between type I DM and Type 2 DM ?

Diagnosis of DM?

Subjective ,

Objective ,

Assessment for this case ?

1 -She has classic symptoms of the disease (polyuria, polydipsia, weight loss, glucosuria, fatigue, recurrent infections)

2-A random plasma glucose above 200 mg/dL

3 -FPG of 126 mg/dL or higher on at least two occasions4

4 -Elevated HbA1c

5 -Features of A.H.’s history that are consistent with type 1 diabetes, in particular, include the relatively acute onset of symptoms in association with a major life event (moving away from home) ,

6 -ketones in the urine ,

7 -negative family history

8 -a relatively young age at onset

9 -vaginal infection.and URTI

This patient has ……………. D.M type I

A.H. will be started on insulin therapy on this visit .

What are the goals of therapy?

A. Prevent the onset of

Acute complications Chronic complications

Hypoglycemia, diabetic ketoacidosis (DKA) Hyperglycemic hyperosmolar nonketotic syndrome

Microvascular: Retinopathy, nephropathy, and neuropathyMacrovascular: Cardiovascular, cerebrovascular, and peripheral vascular diseases

A.H. will be started on insulin therapy on this visit .

What are the goals of therapy for D.M?

B. Glycemic therapy goals

I. HgA1c less than 7.0%.

(Note: The ACE/AACE guidelines recommend 6.5% or less for selected patient those with short duration of diabetes, long life expectancy, and no significant CVD.) II. Less stringent HbA1C goals (such as < 8%)

1. Patient with of severe hypoglycemia,

2. limited life expectancy, advanced microvascular macrovascular complications,

3. extensive comorbid conditions

A.H. will be started on insulin therapy on this visit .

What are the goals of therapy for D.M?

B. Glycemic therapy goals

III. FPG 70–130 mg/dL. Frequency of monitoring very dependent on regimen, type of DM)

IV . Peak postprandial glucose (1–2 hours after a meal) less than 180 mg/dL

C. Non-glycemic therapy goals

BP goal of < 140/ 80 mHg. ( Updated 2013 in ADA guidelines )BP goal < 130/80 mmHg in young patient with no burdenLDL cholesterol < 100 mg/dLHDL cholesterol >50 mg/dL,Triglycerides <150 mg/dL),

Mention chronic complication of D.M ?

Mention acute complications of D.M ?

What are the glycemic control target ?

HbA1c goals in patient with diabetes ?

Blood pressure goals in patient with D.M ?

Lipid profile targets for patient with D.M ?

Sources

I. Koda Kimble , applied therapeutics

II. Pharmacotherapy Bedside Guide Christopher P. Martin, Robert L. Talbert

III. Updates in Therapeutics: The Pharmacotherapy Preparatory Review

IV. Executive Summary: Standards of Medical Care in Diabetes 2013

http://care.diabetesjournals.org/content/36/Supplement_1/S4.full.pdf+html