I.
JUSTIFICATION FOR INTENSIVE DIABETES CONTROL
The following studies have demonstrated that tight glucose control significantly
reduces the presence or progression in microvascular complications of diabetes
mellitus.
A. Diabetes Control and Complications Trial Research Group: The effect of intensive
treatment of diabetes on the development and progression of long-term
complications in insulin-dependent diabetes mellitus. NEJM 329:977-986, 1993.
B. Ohkubo Y, et. al.: Intensive insulin therapy prevents the progression of diabetic
microvascular complications in Japanese patients with non-insulin-dependent
diabetes mellitus: a randomized prospective 6-year study. Diabetes Res Clin Pract
28:103-117, 1995.
C. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control
with sulphonylureas or insulin compared with conventional treatment and risk of
complications in patients with type 2 diabetes (UKPDS33). Lancet 352:837-853,
1998.
II.
KEY PLAYERS OF GLUCOSE REGULATION:
A. Tissues:
1. liver: regulates plasma glucose levels and stores excess as glycogen
2. pancreas: beta-cells create the hormone, insulin, required for glucose uptake
3. insulin-requiring tissues: (muscles, fat)
B. Hormones:
1. Lowers plasma glucose:
insulin
2. Elevates plasma glucose:
glucagon, catecholamines, growth hormone, cortisol
III.
CLASSIFICATIONS:
A. Type 1: 10% of diabetics in U.S.
1. Etiology:
genetic predisposition with environmental factor
2. Pathogenesis: autoimmune or idiopathic destruction of beta-cells
3. Heredity:
as high as 25% risk factor
4. Onset:
acute
5. Age of onset: usually before 40 years/ peak 9-13 years of age
6. Race:
more common in Caucasian
7. Body type: thin, slender
8. Symptoms: polydipsia, polyuria, polyphagia, weight loss, nausea
B. Type 2: 90% of diabetics in U.S./ 50% over 60 years of age are undiagnosed
1. Etiology:
unknown
2. Pathogenesis: insulin resistance of tissue and impaired insulin secretion
3. Heredity:
as high as 75% risk factor
4. Onset:
insidious
5. Age of onset: can be as young as adolescence
6. Race:
African-American, Native American, Hispanic, Asian-American
7. Body type: typically obese
8. Symptoms: very often none
9. Syndrome X: significant risk of type 2 diabetes and heart disease
a) insulin resistance
b) Acanthosis Nigricans
c) lipid abnormalities
d) hypertension
e) upper body obesity
IV.
LABORATORY TESTS:
A. Criteria for the diagnosis of diabetes mellitus:
1. FBS
(Fasting Blood Sugar): > 126 mg/dl
2. RBS
(Random Blood Sugar): > 200 mg/dl with associated symptoms
3. 2-h PG
(2-h postload glucose): > 200mg/dl
4. Abnormality must be confirmed on a subsequent day by any of these tests
B. Other tests:
1. A1C (Glycosylated hemoglobin): assessment of blood sugar control
The glycosylated hemoglobin reflects the average glucose levels over the
preceding 6-10 weeks. It is directly proportional to the time average
concentration of glucose attached to the hemoglobin protein of the red blood
cell. The normal reading is < 6%. The target goal for a diabetic is <7%. One
can convert the A1C readings to mg/dl. A 1% change in A1C roughly equates
to a 30 mg/dl change (e.g.6%=120 mg/dl, 7%=150 mg/dl etc.).
**This test is not currently recognized for the diagnosis of diabetes mellitus.
V.
COMPLICATIONS:
A. CHRONIC:
These complications can occur over the many years of having diabetes. Proper
education and management by health care practitioners are essential in reducing these
complications to a minimum.
1. Macrovascular: association with hyperlipidemia
a) CAD (Coronary Artery Disease): leading cause of death in the U.S.
b) CVA (Cerebrovascular Disease): homonymous field defects,
transient visual loss
c) PVD (Peripheral Vascular Disease): leading to amputation
2. Microvascular: association with hyperglycemia
a) Retinopathy: leading cause of hemorrhage in the retina
b) Nephropathy: CWS, dialysis, tissue edema
c) Neuropathy:
(1) Symmetrical peripheral neuropathy: glove and sock
phenomenon
(2) Autonomic neuropathy: orthostatic hypotension,
hypoglycemic unawareness, gastrointestinal and
genitourinary abnormalities
(3) Acute mononeuropathy: cranial nerve palsies, neurotrophic
corneal ulcers
B. ACUTE :
1. Hypoglycemia: most common presentation in your office
Symptoms:
tremor, diaphoresis, tachycardia, palpitations,
hunger, confusion
2. Hyperglycemia:
a) Diabetic Ketoacidosis (DKA)
b) Hyperosmolar nonketotic coma (HONK)
3. INITIAL T(x) for acute : RAISE GLUCOSE LEVELS
One cannot determine whether a patient is hypoglycemic or
hyperglycemic during an acute attack unless blood tests are performed.
Therefore, the initial treatment for an unknown acute attack is to raise glucose
levels. Raising glucose levels in a hyperglycemic patient is not harmful. A
hypoglycemic patient will significantly benefit as low blood sugar lead to
convulsions, coma, or death. This is why insulin injections should not be
performed as a first line of treatment.
VI.
TREATMENT:
A.
B.
C.
D.
VII.
Nutrition therapy
Activity program: most effective of blood glucose reduction in type 2 diabetics
Oral medications:
1. sulfonylureas: chlorpropamide (Diabinese), glimerpiride (Amaryl), glipizide
(Glucotrol), glyburide (DiaBeta, Micronase, Glynase)
2. meglitinides: repaglinide (Prandin)
3. biguanides: metformin (Glucophage)
4. alpha glucosidase inhibitors: acarbose (Precose), miglitol (Glyset)
5. thiazolidinediones (TZD): rosiglitazone (Avandia), pioglitizone (Actos)
Exogenous insulin
CAUSES OF UNCONTROLLED GLUCOSE LEVELS:
A.
B.
C.
D.
E.
F.
Beta-blockers:
Corticosteroids:
Alcohol:
NSAIDs and salicylates:
Stress: (sickness, infection, mental)
Exercise:
*can mask hypoglycemic symptoms
increases
decreases
decreases
increases
decreases
VIII. PATIENT EDUCATION
A.
B.
C.
D.
E.
IX.
Target blood sugar of 150mg/dl or less (A1C of 7% or less)
Smoking cessation
Aggressive control of blood pressure
Regular follow-up with diabetologist and proper lab tests
Diabetes education
SCREENING FOR DIABETES IN ASYMPTOMATIC INDIVIDUALS
A. All individuals at age 45 years and in 3-year intervals thereafter
B. Testing at a younger age or more frequently in individuals who:
1. have first-degree relatives with diabetes
2. are members of high-risk ethnic populations
3. are obese
4. are hypertensive
5. are dyslipidemic
X.
TEAM APPROACH TO DIABETIC MANAGEMENT
A.
B.
C.
D.
Report findings to diabetologist
Understand team approach model
Advocate quality diabetes care
COMMUNICATION!