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Diabetes Mellitus
group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both
Type 1 Diabetes
A. Immune Mediated accounts for 5-10% of those with diabetes results from a cellular-mediated autoimmune destruction of the -cells of the pancreas markers of the immune destruction of the -cell are usually present in 85-90% of cases commonly occurs in childhood and adolescence, but it can occur at any age, even in the 8th and 9th decades of life
Type 1 Diabetes
B. Idiopathic Diabetes patients have permanent insulopenia but have no evidence of autoimmunity occurs in minority of patients with Type 1 DM, mostly are of African and Asian ancestry strongly inherited
Type 2 Diabetes
accounts for ~90-95% of those with diabetes characterized by impaired insulin secretion, insulin resistance, excessive hepatic glucose production, and abnormal fat metabolism Risk increases with: 1. Age 2. Obesity 3. Physical Inactivity
Acute Complications of DM
1. Diabetic Ketoacidosis 2. Hyperglycemic hyperosmolar state
Manifestations of DKA
A. Symptoms Nausea/vomiting Thirst/Polyuria Abdominal pain Shortness of breath B. Physical findings Tachycardia Dehydration/hypotension Tachypnea/Kussmaul breathing/ respiratory distress Ketotic breath (fruity, with acetone smell)
Manifestations of DKA
B. Physical findings Abdominal tenderness (may resemble acute pancreatitis or surgical abdomen) Lethargy/obtundation/cerebral edema/possibly coma
Precipitating Events
1. Inadequate insulin administration 2. Infection UTI is the single most common
infection associated with diabetic ketoacidosis (pneumonia, gastroenteritis, sepsis)
Chronic Complications
A. Microvascular 1. Eye disease 2. Neuropathy 3. Nephropathy B. Macrovascular 1. Coronary artery disease 2. Peripheral artery disease 3. Cerebrovascular disease
Chronic Complications
D. Other 1. Gastrointestinal (gastroparesis, diarrhea) 2. Genitourinary (uropathy, sexual dysfunction) 3. Dermatologic 4. Infectious 5. Cataracts 6. Glaucoma 7. Periodontal disease
OR
3. 2-h plasma glucose 200mg/dl (11.1mmol/L) during an OGTT - The test should be performed as described by the World
Health Organization, using a glucose load containing the equivalent of 75g anhydrous glucose dissolved in water.*
OR
4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose 200mg/dl (11.1mmol/l)
*In the absence of unequivocal hyperglycemia, criteria13 should be
conrmed by repeat testing.
Prevention/Delay of Type 2 DM
Patients with IGT, IFG, or an A1C of 5.7 6.4% should be referred to an effective ongoing support program for weight loss of 510% of body weight and an increase in physical activity of at least 150 min/week of moderate activity such as walking In addition to lifestyle counseling, metformin may be considered in those who are at very high risk for developing diabetes*
Prevention/Delay of Type 2 DM
Monitoring for the development of diabetes in those with pre-diabetes should be performed every year
Long-Term Treatment
The goals of therapy for type 1 or type 2 DM are: 1. Eliminate symptoms related to hyperglycemia 2. Reduce or eliminate the long-term microvascular and macrovascular complications of DM 3. Allow the patient to achieve as normal a lifestyle as possible
Diabetes Education
Nutrition
Nutrition
as for the general population, diet that includes fruits, vegetables, fiber-containing foods, and low fat milk is advised for weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to 1 year) must be adjusted to meet the goals of individual patients
Exercise
cardiovascular risk reduction reduced blood pressure maintenance of muscle mass reduction in body fat weight loss lowers plasma glucose increase insulin sensitivity
Recommendations
150 min/week (distributed over at least 3 days) of aerobic physical activity in patients with type 2 DM, the exercise regimen should also include resistance training should be under physicians supervision
Glycemic Control
A. Self-Monitoring Blood Glucose (SMBG) standard of care in diabetes management provide a picture of short-term glycemic control B. A1C standard method for assessing longterm glycemic control reflects average glycemic control over the previous 2-3 months
Anti-diabetic medications
A. Oral hypoglycemic agents Sulfonylureas Thiazolidinediones Biguanides Alpha-glucosidase inhibitors D-phenylalinine derivatives Combinations
Sulfonylureas
stimulate insulin secretion by interacting with the ATP-sensitive potassium channel on the beta cell Adverse reactions 1. Hypoglycemia Weight gain - results from the increased insulin levels and improvement in glycemic control
Sulfonylureas
A. First-generation sulfonylureas
1. Chlorpropamide 2. Tolazamide 3. Tolbutamide
B. Second-generation sulfonylureas
1. Glimepiride 2. Glipizide 3. Glyburide
Biguanides
reduces hepatic glucose production decreases intestinal absorption of glucose improves cell sensitivity to insulin
Thiazolidinediones
bind to the PPAR- (peroxisome proliferator-activated receptor) nuclear receptor Decrease insulin resistance Increase glucose utilization Examples: 1. Pioglitazone (Actos) 2. Rosiglitazone (Avandia)
Thiazolidinediones
A. Advantages Lowers insulin requirements B. Disadvantages Peripheral edema CHF weight gain fractures macular edema rosiglitazone may increase risk of MI
-Glucosidase Inhibitors
reduce postprandial hyperglycemia by delaying glucose absorption do not affect glucose utilization or insulin secretion disadvantages diarrhea, flatulence, abdominal distention Examples: 1. Acarbose 2. Miglitol
Insulin
Produced in the -cells of the pancreatic islets Glucose is the key regulator if insulin secretion Glucose levels >3.9mmol/L (70mg/dl) stimulate insulin synthesis
http://www.megahowto.com/how-to-get-your-body-intobalance-between-insulin-and-glucagon
Correlation of A1C with average glucose Mean plasma glucose A1C (%) 6 7 8 mg/dl 126 154 183 mmol/l 7.0 8.6 10.2
9
10 11
212
240 269
11.8
13.4 14.9
12
298
16.5
These estimates are based on ADAG data of 2,700 glucose measurements over 3 months per A1C measurement in 507 adults with type 1, type 2, and no diabetes. The correlation between A1C and average glucose was 0.92 (49). A calculator for converting A1C results into estimated average glucose (eAG), in either mg/dl or mmol/l, is available at http://professional.diabetes.org/eAG.
Summary of glycemic recommendations for non-pregnant adults with diabetes A1C Pre-prandial capillary plasma glucose <7.0%* 70130 mg/dl (3.97.2 mmol/l)
* Referenced to a nondiabetic range of 4.06.0% using a DCCT-based assay. ** Postprandial glucose measurements should be made 12 h after the beginning of the meal, generally
peak levels in patients with diabetes.
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