Overview of Diabetes Mellitus

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Overview of Diabetes Mellitus

• Dr F Dunne
• Dept of Medicine

2
Layout

• Definition
• Diagnosis
• Classification
• Symptoms
• Annual Assessment
• Treatment options

• Metabolic complications
• Macrovascular complications
• Microvascular complications

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Definition

• A syndrome caused by a decrease or total lack of
  insulin or diminished effectiveness of
  circulating insulin (insulin resistance)
• Characterised by hyperglycaemia

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Insulin

• Enhances peripheral glucose uptake
• Inhibits breakdown of liver glycogen
• Enhances storage of glucose as glycogen
• Increases protein synthesis
• Increases triglyceride storage

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Diagnosis

• Fasting blood glucose gt 7mmol/l
• Random blood glucose gt11.1mmol/l
• 75g OGTT

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75g OGTT

• Diabetic FBGgt7 2h gt11.1 mmol/l
• IGT FBG lt7 2h 7.8-11.1 mmol/l
• IFG FBG 6.1-6.9 mmol/l

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Classification

• Type 1 diabetes
• Type 2 diabetes
• Secondary diabetes

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Type 1 diabetesType 2 diabetes

• Juvenille
• Abrupt onset
• Family history
• Autoimmune
• Ketones
• Total insulin def,
• Islet cell AB pos
• HLA DR3 DR4
• Insulin dependent

• Older age
• Slow onset
• Family history
• Not autoimmune
• No ketones
• Partial Insulin def/Resistance
• Insulin requiring
• Diet/OHA

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Secondary Diabetes

• Steroids
• Thiazide Diuretics
• Drugs for HIV
• Pancreatectomy

• Acute pancreatitis
• Chronic Pancreatitis
• Haemachromatosis
• Cystic Fibrosis
• Cushings Disease
• Acromegaly
• MODY
• DIDMOAD

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Symptoms

• Polyuria
• Polydypsia
• Weight loss
• Lethargy
• Tiredness
• Blurred Vision
• Boils/abscesses
• Pruritus Vulvae

• DKA
• Retinopathy
• Nephropathy
• Neuropathy
• Foot ulcers/gangrene
• Angina/MI/CVA

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Annual Assessment

• Osmotic symptoms
• Hypoglycaemia
• Injection sites
• Treatment
• Diabetes nurse specialist
• Dietitian

• Blood pressure
• VAs Fundoscopy
• Pulses/CFT
• Neurology of Legs
• Urinalysis
• HbA1C
• Lipids
• Renal function

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Treatment

• Relief of osmotic symptoms
• Avoid complications
• Choice of treatments dependent on type, age,
  family support etc.

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Treatments of Glucose

• Diet
• Metformin
• Sulphonylureas
• Acarbose
• Thiazolidinediones
• Netaglinide/Repag.

• Rapid acting Insulin
• Long acting Insulin
• Mixed Insulins
• Short acting analogues
• Long acting analogues

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Other treatments

• Anti-hypertensives
• Statins/fibrates
• Aspirin
• ACE inhibitors
• ARBs

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Treat to Target

• HbA1C lt 7
• BP lt 140/80
• Cholesterol lt5 mmol/l
• HDL-C gt1mmol/l
• LDL-C lt 2mmol/l
• Triglycerides lt1.5mmol/l

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Hypoglycaemia lt2.5mmol/l

• Autonomic
• Neuroglycopenic
• LOC
• Cerebral Oedema

• Too much insulin
• Food omission
• Sulphonylureas
• Renal impairement

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Treatment

• Food
• Dextrose tablets
• Hypostop
• Glucose infusion
• Glucagon

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DKA Serious/Life threatening

• Infection
• Omits insulin
• Dehydration
• Ketotic
• Hyperventilating
• Hypotensive
• Tachycardia
• Coma

• Glucose/ketones/
• acidotic on ABG
• IV Fluids
• Insulin
• Potassium
• Antibiotics

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HONK

• Type 2
• Unwell for days
• Not acidotic
• No ketones
• Very high glucose
• Risk of clotting

• Fluids
• Insulin
• Potassium
• Heparin

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Neuropathy

• Peripheral Neurop
• Femoral Amyotrophy
• Mononeuritis multiplex

• Autonomic Neuropathy
• Postural hypotension
• Diarrhoea
• Impotence
• Atonic bladder
• Sweating
• Loss of hypo. awarenes

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Vascular Disease

• PVD
• CVD
• CAD

• Diabetes
• Hypertension
• Proteinuria
• Lipids
• Cigarettes
• Obesity

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PVD

• Intermittent Claudication
• Cold Legs
• Pulseless Leg
• Foot Ulcers
• Gangrene

• Doppler Studies
• Duplex Scanning
• Angiography
• Angioplasty
• Treat risk factors

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CVD

• TIAs
• CVAs
• Dementia

• CT scan
• Carotid Dopplers
• Treat risk factors
• Carotid bypass surgery

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CAD

• Angina
• MI
• Silent infarct
• CCF

• ECG
• Cardiac enzymes
• Troponin I
• Exercise stress test
• Echocardiography
• Angiography
• Angioplasty/CABG

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Diabetic Foot

• Neuropathy
• PVD
• Charcot Arthropathy
• Ulceration

• MRI
• Angiography

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Retinopathy

• Background DR
• Pre-proliferative DR
• Proliferative DR
• Maculopathy

• Fluroscein angiography
• Laser
• Blood Pressure
• Lipids
• Glucose

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Nephropathy

• Diabetic glomerulosclerosis
• Microalbuminuria lt300mg/l
• Proteinuria gt300mg/l
• Nephrotic gt3g/l
• Abnormal creatinine

• Glycaemic control
• BP control
• CAPD
• Transplantation

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Screening

• BMIgt30
• Age gt50
• Ethnic minorities
• Family history
• GDM

• Urinalysis
• FBG
• Random glucose
• OGTT
• Cost/benefit analysis

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Diabetes is preventable by life style modification

• Da Quing (Chinnese)31-46 reduction
• Finnish (Europeans)58 reduction
• DPP (North Americans) 58 reduction
• STOP NIDDM Trial Acarbose
• Lancet 2002359 2072-2077.
• JAMA 2003290 486-494
• TRIPOD Study Pioglitazone

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Literature

• DCCT Trial(Type1) Diabetes 199645 1289-1298
  NEJM 1993329977
• UKPDS study (Type 2) Lancet 1998352837-853
• DIGAMI (CCU)
• BMJ 19973141512-1515
• Lancet 2002259
• Lancet 2000 355 733-777
• ICU patients NEJM 20013451359-1367

• WOSCOPS 4S ASCOT Lancet 20033611149-1158
  (Statin)
• HOPE (ACE-I) NEJM 2000342145-153
• ALL-HAT (ACE-I) JAMA 20022882981-2997
• LIFE SCOPE (ARB)
• CARDS Study (Lancet August 2004)
• DIGAMI 2 study (in press).