Diabetes Mellitus Diabetes Mellitus Hyperglycemia characterized by - PDF document

HIHIM 409 - Clinical Cocepts for Managers Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus Hyperglycemia characterized by relative or Hyperglycemia characterized by relative or absolute lack of insulin secretion absolute lack of insulin secretion Varying degrees of insulin resistance Varying degrees of insulin resistance Oft Often associated with symptoms: polyruia, Often associated with symptoms: polyruia, Oft i t d i t d ith ith t t l l i i Fernando Vega, MD Fernando Vega, MD polydipsia, unexplained weight loss polydipsia, unexplained weight loss HIHIM 409 HIHIM 409 2011 2011 2 Insulin Insulin Diabetes Mellitus Diabetes Mellitus Enhances peripheral glucose uptake Enhances peripheral glucose uptake Normal fasting glucose < 100 Normal fasting glucose < 100 Inhibits breakdown of liver glycogen Inhibits breakdown of liver glycogen Normal postprandial glucose <140 Normal postprandial glucose <140 Enhances storage of glucose as glycogen Enhances storage of glucose as glycogen Increases protein synthesis Increases protein synthesis Increases triglyceride storage Increases triglyceride storage 3 3 4 Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus Another definition Fasting Fasting 2 hours pp 2 hours pp Normal Normal < 100 < 100 < 140 < 140 Hemoglobin A1c equal or greater than 6.5% g q g IFG IFG 100 - 100 - 125 125 IGT IGT 140 140- -200 200 (Adopted by the American Diabetes Association in 2010) Diabetes Diabetes > 126 > 126 > 200 > 200 5 5 6 Fernando Vega, MD 1

HIHIM 409 - Clinical Cocepts for Managers Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus The majority diabetes seen is Type 2 The majority diabetes seen is Type 2 The majority of Type 2 diabetics have no The majority of Type 2 diabetics have no Classification of Diabetes Type 1 – Destruction of pancreatic beta cells awareness of their disease at the time of awareness of their disease at the time of leading to absolute insulin deficiency diagnosis diagnosis diagnosis diagnosis Type 2 – Variable degrees of insulin deficiency and resistance The majority of Type 2 diabetics The majority of Type 2 diabetics Terminology – Are estimated to go undiagnosed or untreated Are estimated to go undiagnosed or untreated Gestational diabetes for months and years for months and years Diabetes secondary to other conditions – Have more insulin than the average person Have more insulin than the average person 7 7 8 Secondary Diabetes Secondary Diabetes Type 1 diabetes Type 2 diabetes Type 1 diabetes Type 2 diabetes Steroids Steroids Acute pancreatitis Acute pancreatitis Juvenille Juvenille (usually) (usually) Older age (usually) Older age (usually) Thiazide Diuretics Thiazide Diuretics Chronic Pancreatitis Chronic Pancreatitis Abrupt onset Abrupt onset Slow onset Slow onset Family history Family history Drugs for HIV Drugs for HIV Haemachromatosis Haemachromatosis Family history Family history Autoimmune Autoimmune Pancreatectomy Pancreatectomy Pancreatectomy Pancreatectomy Cystic Fibrosis Cystic Fibrosis Cystic Fibrosis Cystic Fibrosis Not autoimmune Not autoimmune Not autoimmune Not autoimmune Ketones Ketones No ketones No ketones Cushings Disease Cushings Disease Total insulin Total insulin def def, , Islet cell AB Islet cell AB pos pos Partial Insulin deficiency, Partial Insulin deficiency, Acromegaly Acromegaly HLA DR3 DR4 HLA DR3 DR4 resistance resistance MODY MODY Insulin dependent Insulin dependent Insulin requiring Insulin requiring DIDMOAD DIDMOAD Diet influenced Diet influenced 9 9 10 10 Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus Typical presentations: Prevalence: 7% of the US population has diabetes Patient with diabetic symptoms Patient with diabetic symptoms ½ of them are undiagnosed – Polyuria, polydipsia, weight loss, fatigue Polyuria, polydipsia, weight loss, fatigue The prevalence is increasing – Sleepiness, coma Sleepiness, coma Patient with another illness that Patient with another illness that precipitates a diabetic crisis precipitates a diabetic crisis Patient with discovery on routine Patient with discovery on routine screening screening 11 11 12 12 Fernando Vega, MD 2

HIHIM 409 - Clinical Cocepts for Managers Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus Clinical Management – Acutely Clinical Management – Long Term In office Glycemic control Diet, excercise Inpatient p Oral hypoglycemics yp g y Insulin Assessment of progression Blood pressure control Lipid control Preventing, Monitoring complications 13 13 14 14 Treatments for Hyperglycemia Treatments for Hyperglycemia Other treatments Other treatments Diet Diet Anti- Anti -hypertensives hypertensives Regular Insulin Regular Insulin Metformin Metformin Statins/fibrates Statins/fibrates Long acting Insulin Long acting Insulin Sulphonylureas Sulphonylureas Aspirin Aspirin Analogue insulins Analogue insulins Acarbose Acarbose ACE inhibitors ACE inhibitors Mixed insulins Mixed insulins Thiazolidinediones Thiazolidinediones ARBs ARBs Netaglinide/Repag. Netaglinide/Repag. 15 15 16 16 Treat to Target Treat to Target Diabetes Mellitus Diabetes Mellitus Clinical Course of Diabetes HbA1C < 7% HbA1C < 7% BP < 135/80 BP < 135/80 Immediate consequences Cholesterol <5 Cholesterol <5 mmol mmol/l /l Early consequences y q HDL HDL- -C >1mmol/l C >1mmol/l Late consequences Triglycerides <1.5mmol/l Triglycerides <1.5mmol/l 17 17 18 18 Fernando Vega, MD 3

HIHIM 409 - Clinical Cocepts for Managers Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus Clinical Course of Diabetes - Early consequences Clinical Course of Diabetes - Immediate consequences Tendency to yeast infections Visual blurring Hypoglycemic episodes Weight changes g g 19 19 20 20 Diabetes Mellitus Diabetes Mellitus Neuropathy Neuropathy Clinical Course of Diabetes - Late consequences Peripheral Neurop Peripheral Neurop Autonomic Autonomic Neuropathy Neuropathy Femoral Amyotrophy Femoral Amyotrophy Microvascular Disease: Postural hypotension Postural hypotension Mononeuritis Mononeuritis Neuropathy p y multiplex multiplex multiplex multiplex Diarrhoea Diarrhoea Diarrhoea Diarrhoea Nephropathy Impotence Impotence Retinopathy Atonic bladder Atonic bladder Atherosclerosis Sweating Sweating Loss of hypo. awarenes Loss of hypo. awarenes Coronary artery Peripheral Vascular Disease 21 21 22 22 Nephropathy Nephropathy Retinopathy Retinopathy Diabetic Diabetic Glycaemic control Glycaemic control Background DR Background DR Fluroscein Fluroscein glomerulosclerosis glomerulosclerosis angiography angiography BP control BP control Pre- Pre -proliferative DR proliferative DR Microalbuminuria Microalbuminuria Laser Laser CAPD CAPD Proliferative DR Proliferative DR <300mg/l <300mg/l g Blood Pressure Blood Pressure Blood Pressure Blood Pressure Transplantation Transplantation Transplantation Transplantation Maculopathy Maculopathy Maculopathy Maculopathy Proteinuria >300mg/l Proteinuria >300mg/l Lipids Lipids Nephrotic >3g/l Nephrotic >3g/l Glucose Glucose Abnormal creatinine Abnormal creatinine 23 23 24 24 Fernando Vega, MD 4

HIHIM 409 - Clinical Cocepts for Managers Vascular Disease in Diabetes Vascular Disease in Diabetes Coronary Artery Disease Coronary Artery Disease Angina Angina ECG ECG Peripheral Vascular Disease Peripheral Vascular Disease MI MI Cardiac enzymes Cardiac enzymes Cerebrovascular Disease Cerebrovascular Disease Silent infarct Silent infarct Troponin I Troponin I Coronary Artery Disease Coronary Artery Disease CCF CCF CCF CCF Exercise stress test Exercise stress test Exercise stress test Exercise stress test Echocardiography Echocardiography Angiography Angiography Angioplasty/CABG Angioplasty/CABG 25 25 26 26 Cerebrovascular Disease Cerebrovascular Disease Peripheral Vascular Disease Peripheral Vascular Disease TIAs TIAs CT scan CT scan Intermittent Intermittent Doppler Studies Doppler Studies Claudication Claudication CVAs CVAs Carotid Dopplers Carotid Dopplers Duplex Scanning Duplex Scanning Cold Legs Cold Legs Dementia Dementia Treat risk factors Treat risk factors Angiography Angiography Pulseless Leg Pulseless Leg Pulseless Leg Pulseless Leg Carotid bypass Carotid bypass Carotid bypass Carotid bypass Angioplasty Angioplasty Angioplasty Angioplasty surgery surgery Foot Ulcers Foot Ulcers Treat risk factors Treat risk factors Gangrene Gangrene 27 27 28 28 Diabetic Foot Diabetic Foot Diabetes Mellitus Diabetes Mellitus Clinical Management – Anticipatory prevention Neuropathy Neuropathy MRI MRI PVD PVD Angiography Angiography Evaluation of Diabetic Complications Charcot Arthropathy Charcot Arthropathy Routine Eye exams y Ulceration Ulceration Ulceration Ulceration Routine Foot exams Screening for microalbuminuria Screening for atherosclerosis / coronary heart disease 29 29 30 30 Fernando Vega, MD 5