Diabetes mellitus
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Transcript of Diabetes mellitus
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Regulation of Plasma Glucose Level
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1. Type 1 DM
It is due to insulin deficiency and is formerly known as.
Insulin Dependent DM (IDDM) Juvenile onset DM
2. Type 2 DM
It is a combined insulin resistance and relative deficiency in insulin secretion and is frequently known as.
Noninsulin Dependent DM (NIDDM) Adult onset DM
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Classification of DM
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3. Gestational Diabetes Mellitus (GDM):
Gestational Diabetes Mellitus (GDM) developing during some cases of pregnancy but usually disappears after pregnancy.
4. Other types:
Secondary DM
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Etiology
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1. Etiology of Type 1 Diabetes
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2. Etiology of Type 2 Diabetes
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Insert table 19.6
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Syndrome X or Metabolic Syndrome
Chronic, low grade inflammatory process
Gives rise to diabetes type 2, ischemic heart disease, left ventricular hypertrophy
Group of disorders with insulin resistance as the main feature.
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Clinical Presentation
Type 1 DM
- Polyuria- Polydipsia- Polyphagia- Weight loss- Weakness- Dry skin- Ketoacidosis
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•Type 2 DM
- Patients can be asymptomatic
- Polyuria
- Polydipsia
- Polyphagia
- Fatigue
- Weight loss
- Most patients are discovered while performing urine glucose screening
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Laboratory Tests
1. Glucosuria
To detect glucose in urine by a paper strip Semi-quantitative Normal kidney threshold for glucose is essential
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Laboratory Tests (Cont’d)
3. Fasting blood glucose
Glucose blood concentration in samples obtained after at least 8 hours of the last meal
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4. Random Blood glucose
– Glucose blood concentration in samples obtained at any time regardless the time of the last meal
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Diagnostic Criteria
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Laboratory Tests (Cont’d)
5. Glucose tolerance test
75 gm of glucose are given to the patient with 300 ml of water after an overnight fast
Blood samples are drawn 1, 2, and 3 hours after taking the glucose
This is a more accurate test for glucose utilization if the fasting glucose is borderline
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OGTTNormal mg/dl
Impairedmg/dl
Diabetesmg/dl
FASTING 100 100-125 >126
2Hrs <140 140-199 >200
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Laboratory Tests (Cont’d)
6. Glycosylated hemoglobin (HbA1C)
HbA1C is formed by condensation of glucose with free amino groups of the globin component of hemoglobin
Normally it comprises 4-6% of the total hemoglobin.
Increase in the glucose blood concentration increases the glycated hemoglobin fraction.
HbA1C reflects the glycemic state during the preceding 8-12 weeks.
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Treatment
- Relieve symptoms- Reduce mortality- Improve quality of life- Reduce the risk of microvascular and
macrovascular disease complications- Macrovascular complications: Coronary heart disease, stroke and peripheral
vascular disease
- Microvascular Complications: Retinopathy, nephropathy and neuropathy
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Desired outcome
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Treatment General approaches
- Medications- Dietary and exercise
modification- Regular complication monitoring- Self monitoring of blood glucose- Control of BP and lipid level
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Treatment Nonpharmacological therapy
- For type 1 the goal is to regulate insulin administration with a balanced diet
- In most cases, high carbohydrate, low fat, and low cholesterol diet is appropriate
- Type 2 DM patients need caloric restriction
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Diet
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Treatment Nonpharmacological therapy
- Artificial sweeteners:- e.g. Aspartame, saccharin, sucralose, and
acesulfame- Safe for use by all people with diabetes
- Nutritive sweeteners:- e.g. fructose and sorbitol- Their use is increasing except for acute
diarrhea in some patients
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Diet (Cont’d)
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Treatment Nonpharmacological therapy
- Exercise improves insulin resistance and achieving glycemic control.
- Exercise should start slowly for patients with limited activity.
- Patients with CV diseases should be evaluated before starting any exercise
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Activity
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TreatmentPharmacological therapy
- Insulin (Type 1 and Type 2 DM)- Sulfonylurea (Type 2 DM)- Biguanides (Type 2 DM)- Meglitinides (Type 2 DM)- Thiazolidinediones Glitazones
(Type 2 DM) -Glucosidase inhibitors (Type 2
DM)
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Pharmacotherapy :Type 1 DM
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The choice of therapy is simple
All patients need Insulin
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Insulin
Anabolic
- Glucose uptake- Glycogen synthesis- Lipogenesis- Protein synthesis- Triglyceride
uptake 30
Pharmacological effect:
Anticatabolic
- Inhibits gluconeogenesis- Inhibits glycogenolysis- Inhibits lipolysis- Inhibits proteolysis- Inhibits fatty acid
oxidation
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Diabetes Mellitus Complications
2. Diabetes retinopathy
- Microaneurysm- Hemorrhage- Exudates- Retinal edema- other
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Diabetes Mellitus Complications
3. Diabetes nephropathy
- 30-40 % of all type 1 DM patients develop nephropathy in 20 years
- 15-20 % of type 2 DM patients develop nephropathy
- Manifested as:- Microalbuminuria- Progressive diabetic nephropathy leading to end-
stage renal disease
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Diabetes Mellitus Complications
Diabetes nephropathy (Cont’d)
- All diabetic patients should be screened annually for microalbuminurea to detect patients at high risk of developing progressive diabetic nephropathy
- Tight glycemic control and management of the blood pressure can significantly decrease the risk of developing diabetic nephropathy.
- ACE-inhibitors are recommended to decrease the progression of nephropathy
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Diabetes Mellitus Complications
4. Diabetes neuropathy
Autonomic neuropathy: - Manifested by orthostatic hypotension, diabetic
diarrhea, and difficulty in urination.
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Diabetes Mellitus Complications
5. Peripheral vascular disease and foot ulcer
Incidence of gangrene
of the feet in DM is 20
fold higher than control
group due to:
- Ischemia
- Peripheral neuropathy
- Secondary infection
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Diabetic emergencies
1. Hypoglycemia
- Cause: Missing meals or excessive exercise or too much insulin
- Symptoms: Tachycardia, palpitation, sweating, nausea, and vomiting. Progress to mental confusion, bizarre behavior and coma
- Treatment: Candy or sugar
IV glucose
Glucagon 1 gm IM
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3. Diabetic ketoacidosis
- It is a true emergency
- Usually results from omitting insulin in type 1 DM or increase insulin requirements in other illness (e.g. infection, trauma) in type 1 DM and type 2 DM
- Signs and symptoms:- Fatigue, nausea, vomiting, evidence of
dehydration, rapid deep breathing, fruity breath odour, hypotension and tachycardia
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Diabetic ketoacidosis (Cont’d)
- Diagnosis- Hyperglycemia, acidosis, low serum
bicarbonate, and positive serum ketones
- Abnormalities: - Dehydration, acidosis, sodium and
potassium deficit
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Hypersomolar Hyperglycemic Nonketotic Syndrome (HHNS)
1. Potential complication of Diabetes Type 2
2. Life threatening medical emergency, high mortality rate, as high as 50%
3. Enough insulin is secreted to prevent ketosis, but not enough to prevent hyperglycemia
4. High blood sugar causes an extreme diuresis with severe electrolyte and fluid loss
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Characterized byPlasma osmolarity 340 mOsm/l or greater-
normal 280-300
Blood glucose severely elevated, 800-1000 mg/dl
Altered level of consciousness
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Pathophysiology
a. Hyperglycemia leads to increased urine output and dehydration
b. Kidneys retain glucose; glucose and sodium rise
c. Severe hyperosmolar state develops leading to brain cell shrinkage
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Manifestations
a. Altered level of consciousness (lethargy to coma)
b. Neurological deficits: hyperthermia, motor and sensory impairment, seizures
c. Dehydration: dry skin and mucous membranes, extreme thirst, tachycardia, polyuria, hypotension
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Treatment
a. Usually admitted to intensive care unit of hospital for care.
b. Correct fluid and electrolyte imbalances giving isotonic or colloid solutions and correct potassium deficits
c. Lower glucose with regular insulin until glucose level drops to 250 mg/dl.
d. Monitor for renal failure e. Treat underlying condition