Diabetes Mellitus
What is diabetes mellitus?
Metabolic derangement with
hyperglycemia
How DM is diagnosed?
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Fasting plasma glucose  126 mg/dL
on two occasions
Random plasma glucose  200 mg/dL
with symptoms
Two hours glucose tolerance test with
plasma glucose  200 mg/dL at 2 hour
Glucose intolerance?
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Fasting plasma glucose >110 mg/dL
and <126 mg/dL on two occasions
Two hours glucose tolerance test with
plasma glucose >140 mg/dL and
<200mg/dL at 2 hour
Other causes of
hyperglycemia?
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Endocrine diseases:
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Cushing's syndrome
Acromegaly
Pheochromocytoma
Glucagonoma
Hyperthyroidism
Drug-induced:
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Glucocorticoids
Thiazides
Nicotinic acid
Type of diabetes?
Type 1
 Insulin deficiency
 Early age onset
 Acute onset
 Ketosis
 Thin
Type 2
 Insulin resistance
 Late onset
 Gradual, slow onset
 Usually non-ketotic
 Obese
Diabetes Mellitus type 2
Epidemiology
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Distribution: 75-90% of diabetes mellitus
Incidence:
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3/1000 new cases in Caucasian populations
per year (probably an underestimate)
May be 2-4 times higher according to some
reporting agencies
Prevalence
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Affects 50-70/1000 people in the US
A further 27/1000 have undiagnosed
diabetes on the basis of fasting glucose
Predisposing factors?
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Age:
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Prevalence increases with age
Diagnosed at over 40, although the
group with the largest and fastest
increase in incidence is under age 25
Prior history of gestational
diabetes
Obesity
Predisposing factors
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Race
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Prevalence is increased in:
African-Americans
Hispanic-Americans
Native Americans
Asian-Americans
Pacific Islanders
Pima Indians
Socioeconomic status l
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Lower socioeconomic groups
Predisposing factors
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Genetics
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Positive family history in 30% of cases
Concordance rates of approx. 90% in
identical twins
One first-degree relative doubles the
relative risk and two first-degree relatives
increases the risk 4-fold
Not associated with specific HLA genes
(unlike type 1 diabetes)
Polymorphisms have been identified within
specific ethnic populations Polymorphisms
have been identified within specific ethnic
populations
Symptoms?
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40% are asymptomatic at diagnosis
Lethargy
Malaise
Blurred vision
Polyuria
Polydipsia
Frequent infections, e.g. candidiasis,
balanitis, intertrigo, boils, cellulitis,
urinary tract infections, vaginal yeast
infections; poor wound healing
Symptoms
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50% already develop complicationss
Eye - visual deterioration, blurred
vision
Neuropathy numbness/paresthesias
Angina
Intermittent claudication
Impotence
Physical findings?
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Obesity (BMI >26), especially
centripetal obesity
Eye signs - cataracts,
microaneurysms, hemorrhages,
hard exudates, soft exudates, new
vessel formation, vitreous
hemorrhage, macular degeneration
Physical findings
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Cardiac: congestive heart failure from
prior MI
Foot - decreased peripheral pulses,
decreased protective sensation, absent
ankle-jerk reflex, ulcers
Polyneuropathy, mononeuropathy (less
common than polyneuropathy)
Associated hypertension
Associated metabolic
disorders?
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Blood pressure ≥ 130/85
Glucose intolerance with FBS ≥ 110
mg/dL
Triglyceride >150 mg/dL or HDL <40
mg/dL in males and <50 mg/dL in
females
Abdominal obesity with waist
circumference >102 cm for males and
>89 cm for female
Tests?
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Fasting plasma glucose
Hemoglobin A1c
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Elevated in uncontrolled diabetes, lead
toxicity, iron-deficiency anemia,
hypertriglyceridemia
Decreased in hemolytic anemias, chronic
renal failure
Fasting lipid panel
Bun/Cr
Tests
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Magnesium
Homocysteine – marker for
cardiovascular risk
Urine microalbumin and urinalysis
EKG
Treatments
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Control the hyperglycemia
Management the complications
Treatment options
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Diet
Exercise
Medications
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Stimulating insulin secretion
Block hepatic gluconeogenesis
Increase insulin sensitivity
Decrease GI absorption of glucose
Insulin
Insulin secretagogues
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Sulonylureas
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First-generation – chlorpropamide, tolazamide,
tolbutamide
Second-generation –
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glyburide and glipizide
Glimepiride – enhance peripheral insulin sensitivity
Contraindicated in severe hepatic or renal disease
Meglitinides
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Repaglinide, nateglinide
Attenuated without exogenous glucose
Contraindication in hepatic impairment
Metformin
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Block hepatic gluconeogenesis
Increase muscle sensitivity to insulin
Contraindications
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Cr  1.5 in male and 1.4 in female
CHF
Contrast dye
Thiazolidinediones
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Rosiglitazone and pioglitazone
Increase peripheral sensitivity to insulin
Monitor liver function tests to due to
increased risk of hepatitis
Arbacose
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Diarrhea
Follow LFT periodically
Contraindications
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Hepatic or renal impairment
IBD
GI obstruction
Insulin
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Long acting for basal rate
Short acting for meal
May combine with oral medications
Hemoglobin A1c goal?
< 7%
Aspirin
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Secondary prevention
Primary prevention
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> age 40 with cardiovascular risk factor(s)
Not less age 21 because of increased risk
of Reye’s syndrome
Hypertension goal?
Keep blood pressure < 130/80
mmHg
Cholesterol goal?
LDL < 100 mg/dL
Periodic exams?
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Annual dilated eye exam
Annual monofilament test
Annual urine microalbumin
Annual serum creatinine
Annual fasting lipid panel
Hemoglobin A1c every 3 months
Screening?
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> age 45 and every 3 years
Obesity with BMI >27kg/m2
First relative with diabetes
High-risk ethnic group
GDM or macrosomia baby
HDL 35 mg/dL and TG 250 mg/dL
Disorder associated with insulin resistance
such as PCO
Hypoglycemia: symptoms
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Adrenergic symptoms: tachycardia,
palpitations, tremor, anxiety, and
sweating
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Neuroglycopenic: infaintness,
feeling of hunger, headache,
abnormal behavior, altered
consciousness, and eventually
coma
Hypoglycemia: treatment
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Intravenous or intramuscular
glucagon 1mg
20-50mL of 50% intravenous
dextrose, followed by an infusion
of 10-20% dextrose
Neuropathy
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Peripheral neuropathy – Elavil or
Neurontin
Erectile dysfunction – Viagra
Diabetic foot ulcer
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Control blood glucose
Callus – shaving
Dressing changes
Osteomyelitis leading to amputation