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!