Diabetes Module South Africa 2013
Dr. Shein’s outline
Epidemiology
Increasing prevalence of diabetes and prediabetes
Risk factors in diabetes (including risks contributing to growing prevalence)
Importance of undiagnosed diabetes
Screening for diabetes—considerations
Classification
Type 1 autoimmune
Lack of insulin—insulin is required treatment
Risk for ketoacidosis
Multiple factors—genetics plus environment
Type 2 Insulin resistance + Insulin deficiency (may be relative deficiency considering resistance)
Contributing lifestyle factors
Multiple options for treatment (often together): Oral Rx, insulin/other injections,
lifestyle
Knowledge of the general drug classes and approaches to therapy as discussed
Risk for hyperosmotic state (ketoacidosis uncommon)
Strong genetic comtribution
Complications
Acute
Hyperglycemia
Clinical signs and symptoms including poly’s
Osmotic effects of high glucose levels  water loss in urine
Possible triggers for hyper e.g. infection, non-compliance with meds or diet, etc.
Severe complication of poor control
Diabetic ketoacidosis—may be initial presentation in type 1
Lack of insulin, glucose cannot enter cells
Alternate energy sources generate ketones (and blood acidosis)
Hyperosmotic, hyperglycemic state (w/o ketosis) in type 2
Continued volume loss with blood concentration and increasing glucose
Hypoglycemia
Clinical signs and symptoms (including hypo unawareness)
Inverse relationship of hypo incidence (more with tight control) to DM
complications
Avoidance
Treatment
Patient able to eat—oral sugar (glucose ideal) followed by complex carb
to prevent recurrent hypo
Patient unconscious—glucagon injection or IV fluid with dextrose
Diabetes Module South Africa 2013
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Dr. Shein’s study Outline
Long Term
Microvascular
Ocular
Focus from my material only as relates to comorbid coincidence with other
vascular conditions
Renal
Onset in type 1 not before 5 years
Renal disease may be present in type 2 at diagnosis
Factors contributing to DM often renal diz comorbidities (e.g. HTN)
Renal disease (including proteinuria) is a risk factor for cardiovascular mortality
Screening: Annual urine albumin/creatinine ratio for all diabetic patients
Monitoring: If albuminuria is present, regular monitoring
Risk factor reduction: BP control, smoking cessation, DM control
Treatment for albuminuria/proteinuria to reduce risk of progression:
ACE-inhibitors or ARB (angiotensin II receptor blockers)
Correlation with retinopathy
Neurological
Peripheral neuropathy (“stocking/glove”)
Sensory loss, motor weakness, painful
Consequences: pressure sore, ulcer, infection, gangrene, amputation
Autonomic neuropathy
Gastrointestinal, cardiovascular, genitourinary
Peripheral mononeuropathy
Management, prevention: Glucose control, vascular risk factor reduction
Foot care and monitoring, never go barefoot
Macrovascular
Peripheral vascular disease
Ischemic cardiac disase
Cerebrovascular disease
For each:
Comorbidities
Presentations (symptoms, findings)
Treatment
Skin conditions (key conditions for exam focus)
Infectious
Metabolic
Complications of insulin therapy
Cardiovascular comorbidities—atherosclerosis, hyperlipidemia, hypertension
Pathogenesis of atherosclerotic lesion; key concepts:
Fatty streak (initial lesion, onset may be early in life with risk factors)
Advanced atherosclerotic lesion develops fibrous cap which is prone to rupture
Rupture results in platelet aggregation and potential vessel occlusion resulting in
ischemic event (e.g. heart attack)
Fibrous cap may stabilize and lower risk for rupture with control of lipids, BP, improved
lifestyle
Diabetes Module South Africa 2013
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Dr. Shein’s study Outline
Risk factors
Remember age/gender aggregate—traditional view of male higher risk evaporates at
older ages
Serum lipoproteins (clinical focus)
Clinical signs (focus on ocular)
Role of lipid lowering agents: Focus on statin drugs (primary and secondary prevention)
Role of screening (guidelines vary, key issue—screening is recommended for “at risk”
population)
General understanding of risk reduction schema (consider aggregate of “traditional” risk
factors)
More aggressive goals for higher risk; diabetes is considered in highest risk strata
Aspirin therapy
Benefit of antiplatelet effects in cardiovascular risk reductions
(Strict interpretation of study data suggests MI benefit in men, stroke benefit in
women)
(Not all organizations align recommendation with these findings, some make
blanket cardiovascular risk reduction recommendations w/o gender-specific
guidelines)
Risk of adverse effects—primarily gastrointestinal ulceration and bleeding (ulcers or elsewhere)
Hypertension (HTN)
Substantial worldwide prevalence and increasing (epidemiologic #’s not critical for exam)
Major risk for heart attack and stroke across the globe
Prevalence of:
Undiagnosed HTN and
Untreated HTN
Important to know BP cut-offs for prehypertension and stages 1 and 2
Hypertensive urgency (timely medical office visit) vs malignant hypertension (call medicsemergency)
Essential HTN—90+% of HTN, cause not fully understood
Combination of factors, include genetics, contribution from diet and lifestyle
Secondary HTN—minority of cases, important to consider in specific situations including:
Young age at diagnosis of HTN, abrupt onset of very high BP, electrolyte and/or renal
test abnormalities
End organ effects of chronic HTN
Comorbid risk factors (for risk stratification)
Treatment
Lifestyle modification (including low sodium diet)
Drug treatment—4 major drug classes in common clinical use (think ABCD)
A= ACE-inhibitors, Angiotensin 2 receptor-blockers (ARB)
B= Beta-blockers
C= Calcium channel blockers
D= Diuretics (thiazide class is major one in use)
Misc: Alpha (adrenergic)-blockers—useful also treating prostrate obstruction in older men
Diabetes Module South Africa 2013
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Dr. Shein’s study Outline
Key factor in diabetes—lower BP treatment goal to 140/80 or 130/80 in appropriate patients
Metabolic syndrome: Key message is the continuous variable nature of risk such that borderline
risk factors (preHTN, prediabetes) can contribute to risk, especially when they occur together
with lifestyle risks (overweight); these risks are amenable to lifestyle treatments to reduce risk
Lifestyle is the preferred approach to managing metabolic syndrome
Primary care of diabetes
Review overlap with specific management of diabetes complications, comorbidities and
therapies including:
Tobacco
Diet and weight management
Drug treatments (see above)
Lifestyle management options
Pulmonary
Risk for pneumonia and influenza complications
Role of vaccination in prevention
Dental
Role of chronic dental infections in complicating diabetes control
Role of poorly controlled diabetes in making dental infections more difficult to
control
Diabetes Module South Africa 2013
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Dr. Shein’s study Outline