Transcript DM_Overview

Diabetes Mellitus Overview
Definition
Disease of abnormal carbohydrate
metabolism characterized by
hyperglycemia
Caused by:
– Impairment in insulin secretion and/or
– Peripheral resistance to insulin
???
True or False
Diabetes insipidus is the opposite of
diabetes mellitus, in other words, a
problem of low blood sugar.
False
Diabetes insipidus
– Disorder involving the secretion or response
to ADH (antidiuretic hormone)
– Causes high-volume urine output and
hypernatremia
– Not a glucose problem
Diabetes Mellitus
Over 7% of U.S. population
14% of health care expenditures
132 billion dollars (2002)
Associated with:
– Higher psychiatric illness
– Decreased work productivity
– Increased absenteeism
Diabetes Mellitus
Type 1: destruction of pancreatic beta
cells leading to insulin deficiency (10%)
Type 2: insulin resistance with varying
degrees of insulin deficiency (80%)
Gestational: insulin resistance created by
anti-insulin hormones secreted by
placenta during pregnancy
Other causes: drugs, infections
Type 1 DM
Autoimmune destruction of insulinproducing cells in pancreas
– Islet cell autoantibodies
– Glutamic acid decarboxylase antibodies
– Anti-insulin antibodies
– Associated with other autoimmune diseases
Genetically susceptible
Triggered by environmental agent
???
Diabetes mellitus damages:
A.
B.
C.
D.
E.
Eyes
Kidney
Nerves
Heart
Brain
Complications
Microvascular
– Nephropathy
– Neuropathy
– Retinopathy
Macrovascular
– Coronary artery disease
– Peripheral vascular disease
– Stroke
Diabetic nephropathy
Microalbuminuria > Macroalbuminuria >
Elevated creatinine > End stage renal
disease > Dialysis
Asymptomatic
Diabetic neuropathy
18% have evidence of nerve damage at
diagnosis
Usually symmetrical, affecting lower
extremities first
Stocking-glove syndrome
Impaired sensation (pain, light touch,
temperature, vibration, proprioception)
Can feel numb or painful
Diabetic neuropathy
Major risk factor for foot ulcers
Autonomic neuropathy
– Postural hypotension
– Gastroparesis
– Enteropathy (constipation/diarrhea)
Diabetic retinopathy
Most common cause of blindness in
middle-aged people
Blindness 25x higher in diabetics
Asymptomatic until late stages
80% of type 2’s have retinopathy at 20y
Mechanisms
– Impaired blood flow
– Accumulation of sorbitol in retina
Diabetes and the Heart
Diabetics have:
– Higher rate of heart disease
– Greater coronary ischemia
– Higher chance of MI and silent MI
CHD risk equivalent
– Aggressive LDL goal
???
Per ADA, DM (type 2) screening should
begin at what age?
A. 25
B. 35
C. 45
Screening
Start at age 45; if normal repeat every 3
years
Screen earlier or more frequently if
overweight with additional risk factor
– Inactive
– Family history (1st degree relative)
– HTN
– IFG or IGT
– Vascular disease
Diagnosis
American Diabetes Association
Fasting plasma glucose
Random glucose with symptoms
Oral glucose tolerance test
Should be confirmed with repeat testing on
different day
Diagnosis
Fasting plasma glucose
Fasting = no caloric intake for 8 hours
Greater than or equal to 126 mg/dl
Diagnosis
Random glucose with symptoms
Glucose greater than or equal to 200
mg/dl at any time
Classic symptoms: polydipsia, polyuria,
weight loss
Diagnosis
Oral glucose tolerance test
Glucose greater than or equal to 200
mg/dl two hours after 75g glucose load
Treatment
Nonpharmacologic (lifestyle)
– Proper diet
– Exercise
– Weight loss
Benefits greater to type 2’s
Drug treatment
Insulin
- Initial treatment in type 1’s
- In type 2’s, more commonly used after oral
agents fail
Multiple daily injections
– Lantus + Humalog
Continuous infusion
Adjustments based on HgbA1c and daily
glucose checks
Drug treatment
Metformin
Sulfonylureas
Meglitinides
Thiazolidinediones
Alpha-glucosidase inhibitors
Metformin
Decreases liver glucose production
Improves insulin sensitivity
Modest weight reduction
Avoid in renal insufficiency
Avoid before IV contrast load or surgical
procedure (lactic acidosis)
Start 500mg once daily with dinner
???
Metformin should be held ___ hours
before IV contrast studies.
A.
B.
C.
D.
8
24
48
96
Sulfonylureas
Increase insulin release
Oldest class of oral agent
Higher rate of hypoglycemic complications
Starting doses
– Glipizide 5mg daily
– Glyburide 2.5 to 5mg daily
– Glimeperide 1 to 2 mg daily
Meglitinides
Increase insulin release
Short-acting, expensive
Taken with meals
Starlix, Prandin
Thiazolidinediones
Increases insulin sensitivity
Less effective than metformin and
sulfonylureas as monotherapy
Causes weight gain, fluid retention
Avoid in heart failure
Alpha-glucosidase inhibitors
Modifies intestinal absorption of
carbohydrate
Less potent than oral agents (0.5-1% A1c
reduction)
Main side effects: gas, diarrhea
Take with meals
Persistent hyperglycemia
Combination therapy (type 2’s)
– 2 or 3 drugs together
– 2 orals then add insulin if needed
– No need for sulfonylurea and insulin together
Exenatide (Byetta)
– Twice daily subcutaneous injection
– Promotes weight loss
– GI side effects
– Overweight patient gaining weight on orals
???
True or False
Insulin can be inhaled.
Persistent hyperglycemia
Inhaled insulin
– Rapid, similar to lispro insulin
– Taken with meals
– Excludes patients with respiratory disorders
– Long-term effects on lungs not defined
Long-term care
HgbA1c (goal < 7%)
7% = 150 (1% change = 30)
Glucose targets (frequency 2-4x day)
– Preprandial (90 to 130)
– Postprandial (<180)
Long-term care
Routine eye exams
– Dilated and comprehensive exam shortly after
diagnosis
– Annual exams thereafter
– Ophthalmologist or optometrist recommended
Long-term care
Routine foot exams
– Detect or monitor vascular/neurologic
complications
– Visual inspection of feet at each routine visit
– Comprehensive exam yearly
Pulses
Monofilament test
Long-term care
Screen or treat microalbuminuria
– Dipstick is insensitive
– Spot urine collection measuring albumin to
creatinine ratio
> 30mg/g abnormal
ACE-inhibitor or ARB prevents
progression of nephropathy
Long-term care
Aggressively treat cardiac risk factors
– Smoking
– Hypertension (< 130/80)
– Dyslipidemia (LDL < 100)
Aspirin (81mg) for 1° CHD prevention for
anyone with one risk factor
Acute complications
Diabetic ketoacidosis
–
Metabolic acidosis is main concern
Nonketotic hyperglycemia
–
–
Glucose often > 1000
Neurologic abnormalities frequent
Precipitating factors: MI, pancreatitis, trauma,
any stress to body
Treatment requires IV insulin, hydration,
electrolyte replacement
Questions?