Download type 2 diabetes

Diabetes Mellitus
Fifth Stage-Medicine
Dr. Sarbast Fakhradin
MBChB, MSc Diabetes Care & Management
CLINICAL
EXAMINATION OF
THE PATIENT WITH
DIABETES
Pathophysiological basis of the symptoms and signs of uncontrolled diabetes
mellitus.
Symptoms of hyperglycaemia:
• Thirst, dry mouth
• Polyuria
• Nocturia
• Tiredness, fatigue, lethargy
• Noticeable change in weight (usually weight loss)
• Blurring of vision
• Pruritus vulvae, balanitis, genital candidiasis (Infection)
• Nausea; headache
• Hyperphagia; predilection for sweet foods
• Mood change, irritability, difficulty in concentrating, apathy
• Type 2 diabetes may have an insidious onset of hyperglycemia and
may be relatively asymptomatic initially particularly in obese
patient.
Differences between type1 &2:
Type1
Type2
Age of onset
<40 years
>50 years
Duration of symptoms
Weeks
Months-years
Body weight
Normal or low
Obese
Ketonuria
Yes
No
Autoantibody &other autoimmune
disease
Yes
No
Diabetic complication at diagnosis
No
Yes 10-20%
Family history of diabetes
uncommon
common
Acute complication
Ketoacidosis
Hyperosmolar nonketotic coma
Overlap may occur between the types
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• Latent Autoimmune Diabetes in Adults
(LADA) is a form of autoimmune (type 1) which is diagnosed
in individuals who are older than the usual age of onset of type 1
diabetes. Often, patients with LADA are mistakenly thought to
have type 2 diabetes, based on their age at the time of diagnosis.
 MODY – Maturity Onset Diabetes of the Young: is a
monogenic form of diabetes with an autosomal dominant mode of
inheritance, Different subtypes of MODY are identified based on
the mutated gene. It can occur at any age and family history of
diabetes is not always obvious.
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Metabolic Syndrome (Syndrome X)
• It’s a coexistence of a cluster of conditions, all of which predispose
to cardiovascular disease. Insulin resistance is the primary defect
and the presence of obesity is a powerful amplifier of the insulin
resistance.
• Features of the metabolic syndrome
• Hyperinsulinaemia
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Type 2 diabetes or impaired glucose tolerance
Hypertension
Low HDL cholesterol & elevated triglycerides
Central (visceral) obesity
Microalbuminuria
Increased fibrinogen
Increased plasminogen activator inhibitor-1
Increased C-reactive protein (CRP)
Elevated plasma uric acid
1. Urine testing
• (Glycosuria)
Investigation
Best to do it 1-2hours after main meal which select much milder cases than fasting urine.
Disadvantage is individual variation in renal threshold for glucose.
Differential diagnosis of glycosuria:
1. DM
2. Non diabetic glycosuria due to glucose.
Glucose appeared in urine despite normal blood glucose e.g. Fanconi’s syndrome,
dysfunction of the proximal renal tubules, chronic renal failure, pregnancy(common to have
glyosuria by ↑GFR during pregnancy&↑glucose load 50% of pregnant has sugar in urine
specially after the 1st trimester & in the last weeks lactose may be present).
3. Non diabetic glycosuria due to sugars other than glucose, lactosuria during late
pregnancy & lactation is most common.
4. Alimentary glycosuria (lag storage).
Normal or after gastric surgery or hyperthyroidism or hepatic disease, this is benign &not
related to diabetes.
• Ketonuria:
Conditions leads to ketonuria apart from DKA are starvation, high fat diet,
alcoholic ketoacidosis, fever, exercising strenuously for long periods, &
repeated vomiting.
• Protein:
Standard dipstick testing for albumin detects urinary albumin at concentrations >
300 mg/day. but smaller amounts (microalbuminuria: 30-299 mg/day) can only
be measured using specific albumin dipsticks or by quantitative biochemical
laboratory measurement
• 2. Blood glucose levels:
• Laboratory glucose testing in blood relies upon an enzymatic
reaction (glucose oxidase) and is cheap, usually automated and
highly reliable. Glucose concentrations are lower in venous than in
arterial or capillary (fingerprick) blood.
• Whole blood glucose concentrations are lower (10-15%) than
plasma concentrations because red blood cells contain relatively
little glucose. In general, venous plasma values are the most
reliable for diagnostic purposes.
• 3. Glycated hemoglobin (HbA1c):
• It is a slow non-enzymatic covalent attachment of glucose to
haemoglobin (glycation) increases the amount in the HbA1
(HbA1c) fraction relative to nonglycated adult haemoglobin
(HbA0). Glycated haemoglobin provides an accurate and objective
measure of glycaemic control over a period of weeks to months.
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The rate of formation of HbA1c is directly proportional to the
ambient blood glucose concentration; a rise of 1% in HbA1c
corresponds to an approximate average increase of 2 mmol/L (36
mg/dL) in blood glucose.
• HbA1c concentration reflects the integrated blood glucose control
over the lifespan of the erythrocyte (60-120 days). The
recommended target HbA1c is 7% or less, to minimise the risk of
vascular complications.
Diagnosis
• Patient complains of symptoms suggesting diabetes + one
abnormal blood glucose.
• In asymptomatic patients two samples are required to confirm
diabetes.
• When a diagnosis of diabetes is confirmed, other investigations
should include plasma urea, creatinine and electrolytes, lipids, liver
and thyroid function tests, and urine testing for ketones, protein or
microalbuminuria.
• The diagnostic criteria for diabetes in pregnancy are more stringent
than those recommended for non-pregnant subjects. Pregnant
women with abnormal glucose tolerance should be referred
urgently to a specialist unit for full evaluation.
• Stress Hyperglycemia:
• In some people, an abnormal blood glucose result is
observed under conditions which impose a burden on the
pancreatic β cells, e.g. during pregnancy, infection,
myocardial infarction or other severe stress, or during
treatment with diabetogenic drugs such as
corticosteroids. It usually disappears after the acute
illness has resolved. However, blood glucose should be
remeasured and an OGTT will often show persistence of
impaired glucose tolerance.
Oral Glucose Tolerance Test
• Indications:
1. IFG
2. IGT
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How to perform an OGTT:
Unrestricted carbohydrate diet for 3 days
Fasted overnight for at least 8 hrs
Rest for 30 mins
Remain seated for the duration of the test, with no smoking
Plasma glucose is measured before and 2 hrs after a 75 g oral
glucose drink
Management
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1. Education
2. Lifestyle modification alone (50%)
3. Lifestyle modification + Oral antihyperglycemic (20-30%)
4. Lifestyle modification + Insulin (20-30%)
5. Lifestyle modification + Oral agents + Insulin
New/Future treatments – Type 1 DM
• Insulin pump
• Stem cells research: Bone marrow, cord blood,
panceatic, embryonic.
• BCG
• Islet transplantation.
Comprehensive diabetes care of type 2
DM
Thank you
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