DIABETES MELLITUS

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DIABETES MELLITUS

• THOMAS MILLIGAN, DO
• OSU-COM
• FAMILY MEDICINE

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Introduction

• Types of DM
• Diagnosis
• Management
• Follow-up
• Complications

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TYPES

• Type 1
• Type 2

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TYPE 1

• Pathophysiology
• Diagnosis
• Management

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DIAGNOSIS

• Random BS of 200 plus symptoms
• Polyuria
• Polydipsia
• Unexplained weight loss
• Fasting BS 126 or Greater
• NPO at Least 8 Hours
• BS of 200, 2 Hours After 75g Glucose Challenge

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MANAGEMENT

• Diet
• Decrease Glucose
• Pt Must Not Skip Meals
• Exercise
• Insulin

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PATHOPHYSIOLOGY

• Immune related destruction of insulin producing
  cells
• Loss of insulin
• Insulin required to prevent DKA

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INSULIN

• Begin with 20 - 40 u day
• 2/3 am, 1/3 pm
• Am 2/3 inter, 1/3 regular
• Pm 1/2 inter, 1/2 regular
• Timing
• Must be given with respect to meals

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INSULIN

• Adjustments
• Average of 35 - 50 u day
• 0.6 - 1.2 u/kg/day
• Maintain FSBS 100 - 250
• Pt keeps log of FSBS to avoid hypoglycemia
• Intermediate insulin
• Change evening dose first
• Beware of nocturnal hypoglycemia

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INSULIN

• Regular insulin
• Guided by pre-prandial FSBS
• Avoid regular insulin at bedtime
• More diet and activity sensitive
• Multiple Daily Injections (MDI)
• Better control
• Very compliant pts

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INSULIN

• ONSET PEAK
  DUR
• LISPRO 15 - 30 m 1 - 3 h 3 - 6
  h
• REGULAR 15 - 60 m 2 - 6 h 4 - 12 h
• NPH 1.5 - 4 h 6 - 16 h 14
  -28 h
• LENTE 1 - 4 h 6 - 16 h 14
  -28 h

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TYPE 2

• Pathophysiology
• Diagnosis
• Management

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PATHOPHYSIOLOGY

• Usually after age 30
• Usually obese
• Insulin resistance
• Insulin may be used, but not essential
• Non ketotic hyperosmolar syndrome, not DKA

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DIAGNOSIS

• Random bs of 200 plus symptoms
• Polyuria
• Polydipsia
• Unexplained weight loss
• Fasting BS 126 or greater
• NPO at least 8 hours
• BS of 200, 2 hours after 75g challenge

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MANAGEMENT

• Diet
• Exercise
• Oral agents
• Combination
• Insulin

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ORAL AGENTS

• Sulfonylureas
• Metformin
• Troglitazone
• Acarbose

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SULFONYLUREAS

• Diabinese, glucotrol, diabeta, micronase,
  prandin, amaryl
• Increases insulin production
• Hypoglycemia

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METFORMIN

• Glucophage
• Decreases hepatic glucose production
• No hypoglycemia

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TROGLITAZONE

• Rezulin
• Increases peripheral glucose uptake
• No hypoglycemia if used alone
• Initial indication is for pts on insulin
• Liver toxicity

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ACARBOSE

• Precose
• Alpha-glucosidase inhibitor
• Decreases glucose uptake in the gut
• GI intolerance
• No hypoglycemia

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COMBINATION

• Use one from each class
• Reduce dose of other drugs by 1/2 if adding a
  sulfonylurea

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INSULIN

• Max out oral agents
• Start with intermediate acting insulin
• Eventually will use one modality

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EVERY VISIT

• FSBS
• UA with microalbumin
• Foot exam, including neuro

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EVERY 3 MONTHS

• HGB A1C

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EVERY 6 MONTHS

• Lipids
• CHEM 8

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YEARLY

• Ophthomology consult
• EKG

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COMPLICATIONS

• Retinopathy, neuropathy, cad, nephropathy,
  enteropathy, poor wound healing, impotence,
  depression
• Hyperglycemia is better than no glycemia