Diabetes Mellitus

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Diabetes Mellitus

• Biochemistry
• Clinical Correlations

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Diabetes Mellitus (DM)

• DM is a condition of hyperglycemia or an increase
  in blood sugar.
• Random Blood Glucose is gt 200
• Most common of all endocrine disorders
• Diabetes running through
• Mellitus sweet
• Excess blood sugar spills into the urine ? sweet
  urine

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Diabetes Mellitus (DM)

• DM affects 6 of the US population
• That is roughly 14 million people
• 50 of those are undiagnosed
• It is predicted to be at 10 by 2010

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Diabetes Mellitus (DM)

• Hormone Functions
• Insulin - ?glucose uptake by cells
• - ?blood glucose
• - ?hepatic glucose prod
• Glucagon - ?blood glucose
• - ?hepatic glucose prod
• - ?ketone production

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Diabetes Mellitus (DM)

• Bloodstream
• Glucose

Glucose
transporters
Pancreas
Liver
Beta cells
Insulin receptors
Insulin
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Diabetes Mellitus (DM)

• Causes of Hyperglycemia
• ?glucose uptake by cells (insulin
  sensitivity)
• ?hepatic glucose production
• ?insulin production by beta cells of the
  pancreas (insulin deficiency)
• High rate of glucagon secretion in DM intensifies
  hyperglycemia

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2 Types of Diabetes Mellitus

• 5 DM type1 insulin dependent DM (IDDM)
• No insulin secretion
• Require insulin to survive
• 95 DM type 2 non-insulin dependent DM (NIDDM)
• Insulin resistance, grad. ? insulin
• Gestational Diabetes occurs during pregnancy

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Characteristics of DM Type 1 2

• DM1
• Young individ. lt40 yrs
• Normal/ low weight
• Caucasian
• Abrupt onset
• Autoimmune
• Weak genetic component

• DM 2
• Middle age/ older gt40yrs
• Overweight
• Afro-Amer, Hispan-Amer, Native Amer (esp. Pima)
• Slow onset
• Strong genetic component

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Symptoms of DM 1 2

• Fatigue
• Polyuria
• Nocturia
• Polydipsia
• Dizziness
• Poor Wound Healing

• Vaginitis yeast
• ? Infections
• Weight loss (DM1)

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Risks for Developing DM 2

• Obesity
• Tobacco Use
• Family history of DM 2
• ? BP
• ? Cholestrol - ?TG, ?HDL
• Sedentary lifestyle

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Diagnosis of DM

• Fasting serum glucose gt 130
• Postprandial serum glucose gt 200
• Glucose Tolerance Test (GTT)
• Glucosuria serum glucose gt 200
• Hemoglobin A1c gt 6.0 (controversial)

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Hemoglobin A1c (Hgb A1c)

• Glycosylated Hemoglobin
• RBCs live for 90 days
• Glucose attaches to RBC (glycosylated)
• RBCs are counted, the higher the of
  glycosylated RBCs, the higher the serum glucose
• Test provides an ave glucose level for the
  previous 3 mons

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Managing Diabetes Mellitus

• Exercise potentiates insulin action ?blood
  glucose
• Recommend 30-60 min 3-5 days weekly
• Diet Carbs 55-60
• Fat 30
• Protein 10-15
• Self Monitoring of Glucose Levels
• DM2 controlled 1x daily
• DM2 uncontrolled 3x daily
• DM1 3-5x daily
• Diabetic Counselling

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Managing Diabetes Mellitus

• OV every 3 mon
• ? BP
• Fasting glucose
• Bun/Cr- renal func
• Hgb A1c (lt6.5)
• UA gluc, protein

• OV every 6 mon
• Cholestrol
• Urine microalbumin (ACEI)
• Sensation testing
• Foot exam
• Repeat labs from 3 mon check

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Medication for DM 1

• Insulin
• Onset Peak Dur
• Short acting 30 min 2-4hrs 5-7hrs
• (Regular or semilente)
• Inter. Acting 1-2hrs 6-12hrs 18-24hr
• (NPH or Lente)
• Long acting 4-6hrs 8-16hrs 24-36hr
• (ultralente, Lantus)

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Oral Medication for DM 2

• Metformin (Glucophage)
• ?insulin sensitivity, ?hepatic glucose prod
• Side effects wt loss, lactic acidosis
• Sulfonylureas (Glucotrol, Amaryl)
• ?insulin secretion
• Side effects hyponatremia,hypoglycemia
  (hunger, drenching sweat, tremors, confusion)
• Insulin Sensitizers (Actos, Avandia)
• ?insulin sensitivity

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Managing Medications in DM 2

• 1st Metformin (?insulin sens)
• 2nd contin Metformin
• add Sulfonylurea (?insulin prod)
• 3rd contin Metformin Sulfonylurea
• add Insulin sensitizer
• 4th contin Metformin Insulin Sensit.
• add Insulin (Lantus)

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Acute Complications of DM 1

• Ketoacidosis
• Complete lack of insulin?unrestrained lipolysis
• Causing ?circulating fatty acids??ketone body
  prod by liver (metabolic acids)
• Metabolic acids accumulate in excess of what the
  body can handle excrete, so metabolic acidosis
  occurs

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Symptoms of Ketoacidosis

• Nausea Vomiting
• Confusion
• Excessive thirst
• Headache
• Abdominal pain
• Drowsiness
• Myalgias

• Hypotension
• Tachycardia
• Fruity odor of breath
• Dehydration
• Hyperpnea (Kussmals)
• Urine ketones
• ?pH, ?K, ?P

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Treatment of Ketoacidosis

• IV Insulin
• IV fluids

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Acute Complications of DM 2

• Hyperosmolar Nonketotic Coma
• ?serum glucose, serum osmol gt 380
• S/S lethargy, dehydration, usually concurrent
  w/ illness, stroke, diuretics, trauma
• Treatment large volumes of fluid, insulin
  slowly over 12-24 hrs.

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Long Term Complications of DM

• Retinopathy
• loss of vision due to hemorrhage, lesions,
  etc.
• leading cause of blindness in lt60yrs
• occurs about 7 yrs after onset
• regular ophthalmology visits

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Long Term Complications of DM

• Nephropathy
• Renal disease/failure
• 1st sign microalbuminuria
• Appears 8-12 yrs after onset
• ?by using Ace inhibitors (BP med)
  following low protein diet

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Long Term Complications of DM

• Atherosclerosis
• ?blood supply, acclerated in DM
• ?risk stroke, Coronary artery dz
• Causes 50 of nontraumatic amputations
• ?cholestrol

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Long Term Complications of DM

• Neuropathy
• ?peripheral sensation cant feel minor
  cuts, blisters
• Develops gradually, impossible to reverse
• Numbness, tingling, pain in toes hands
• Slowly progresses proximally

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Other Complications of DM

• Impotence/ erectile dysfunction
• Urinary Retention
• Gastroparesis difficulty emptying stomach,
  ?absorption of meals
• GERD reflux
• Shinspots hyperpigmented lesions

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Gestational Diabetes Mellitus

• Caused by gestational counter-insulin which
  limits ability to secrete insulin
• Dangerous to developing fetus
• Treatment is insulin only, no oral meds
• Screening between 24-28 wks
• Glucose returns to normal postpartum in 75
• At higher risk of developing DM 2
• Results in Large Babies

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Secondary types of DM

• Surgical removal of pancreas
• Chronic pancreatitis
• Disease of Pancreas
• Other endocrine disorders
• Drugs thiazide diuretics

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Highlights of DM

• Difference betw. DM 12 (insulin resist vs defic)
• Characteristics of each
• Standard Diagnosis
• Definitive Diagnosis
• Acute complications of DM 1
• Acute complications of DM 2
• Which 2 other conditions need treated along w/ DM