Download DIABETES-Dec 2016

FAMILY MEDICINE
COURSE
TOPIC:
Diabetes Mellitus
OBJECTIVES:
At the end of this session, students will be
able to:
1. Identify D/D of a case presented with the
symptoms of polyuria and polydipsia.
2. Identify the prevalence of diabetes
mellitus (DM) in Saudi community.
3. Discuss the classification of DM .
OBJECTIVES (Continued):
4. Discuss briefly about the diagnostic
criteria for DM.
5. Identify the patho-physiological
changes in a diabetic patient.
6. Enumerate and discuss the
importance presenting signs &
symptoms of DM.
OBJECTIVES (Continued):
7. Investigate appropriately a patient suspecting of
DM.
8. Advice initial management plan for a patient
diagnosed first with DM.
9. Identify important complication of DM
10. Discuss different medication used in DM
management .
11. Identify importance of life style changes in
diabetic patients.
12. Discuss screening criteria for DM.
CASE:
A 30-year-old man, who works as a clerk in a
company , has presented to the clinic today with
the complaint of increased thirst, and increased
urination . These complaints initiated for last few
weeks. He admitted that he was in Makkah for
Omra and started to have these symptoms, but he
assumed that these symptoms were due to hard
works and running from here to there in Makkah.
But he is worried that the symptoms are continuing
even he is back home and having usual sedentary
life.
CASE (Continued):
He also complaint of generalized weakness,
otherwise on other complaint. He is not
known to have any other chronic illness.
On Examination:
Look well. His height is 160 cm and his
weight is 98 kg.
Systematic examination reviled normal, apart
from being obese.
Summarize the case.
 What are the possible causes
of his symptoms? (Differential
diagnosis )
Write down on a paper before
moving to the next slides
Summary of the case:
 A 30-year-old man, not known to have any
problem before, with sedentary life.
 C/o generalized weakness, polyuria and
polydipsia of recent onset.
 His height is 160 cm and his weight is 98 kg.
Differential diagnosis for polyuria and polydipsia.
 Diabetes mellitus.
 Diabetes insipidus.
 Nephropathy( hypokalemic).
 Hyperparathyroidism.
 Cushing's disease/Syndrome.
 Compulsive water drinking.
 Pheochromocytoma.
What
is the prevalence
of DM?
Prevalence of DM World wide
• More than 350 million people have diabetes.
• Predicted to be the 7th leading cause of death
by the year 2030.
• 80% of diabetic deaths occur in low and
middle income countries.
• One third of people with diabetes are
undiagnosed.
Prevalence of DM
In saudi arabia
• In 1988, 4% of Saudis were diabetic.
• Nearly 25% of Saudis are diabetic in 2015.
• 4 million are in risk.
What is diabetes mellitus ?
A group of heterogeneous metabolic disorders
which is characterized by abnormal metabolism of
glucose due to defect in : insulin secretion or
insulin action
How to diagnose
diabetes ?
Criteria for the diagnosis of diabetes.
A1C≥6.5% FPG≥126mg/
dl
*In
2-h≥200 mg/dl
classic
symptom +
RPG≥200mg/dl
the absence of unequivocal
by ‫ز‬hyperglycemia, results should be confirmed
repeat testing
Who are normal
People i.e. not
diabetic?
FBS: < 5.5 mmols/L (< 100 mgs)
2PP: < 7.8 mmols/L (<140 mgs)
HbA1c: < 5.6 %
How about
asymptomatic
adults ?
Who are
Pre-diabetic
Patients?
Pre-diabetic condition :
The term used for individuals with impaired fasting
glucose (IFG) and/or impaired glucose tolerance
(IGT).
And indicates an increased risk for the future
development of diabetes.
FBS: 5.6- 6.9 mmols/L (100-125mgs)
HbA1c: 5.7- 6.4 %
2-h PG after 75-g OGTT: 7.8-11 mmols/L
(140–199 mg/d)
Screening for DM !!
Criteria for testing for diabetes in asymptomatic adults
1. Testing should be considered in all adults who are
overweight (BMI ≥25 kg/m2)
and have additional risk factors:
first-degree relative with
diabetes
high-risk
race/ethnicity
women who delivered a baby weighing .9 lb or were diagnosed
with GDM hypertension.
women with polycystic ovary
syndrome
history of CVD
Screening for DM !!
Criteria for testing for diabetes in asymptomatic adults
2. For all patients, particularly those who are overweight or obese,
testing should
begin at age 45 years.
3. If results are normal, testing should be repeated at a minimum
of 3-year intervals.
Usually pre-diabetic conditions are detected through
this screening .
How to Classify
DM?
Diabetes Mellitus Classification:
Type 1:
β-cell destruction, usually
leading to absolute insulin deficiency;
Immune-mediated diabetes.
 Type 2: Ranging from predominantly
insulin resistance with relative insulin
deficiency to predominantly an insulin
secretary defect with insulin resistance)
 Gestational diabetes mellitus (GDM):
diagnosed in the second or third trimester
of pregnancy
Others:
Diabetes can be classified into the
following general categories:
Others /Specific types
Genetic
disorders
Endocrine
disorders
* Neonatal diabetes
diabetes
* Maturity-onset
of the young [MODY]
*
*Acromegaly
syndrome
*Cushing’s
*Pheochromocytoma
Pancreatic
disorders
Monogenic diabetes Pancreatic agenesis
* Cystic fibrosis
syndromes
* Pancreatitis
* Tumor
*
Drug-induced
diabetes
*Steroids
blockers
*Beta
*thiazide diuretics
What are the pathophysiology
of
Diabetes Mellitus?
Impaired fasting glucose:
 Patients whose plasma glucose levels are higher
than normal but not diagnostic of DM
 Risk factors for developing DM and
cardiovascular disease and are associated with the
insulin-resistance syndrome.
5% to 10% of all diabetes cases.
Childhood or early adulthood
Results from immune- mediated destruction of
pancreatic β-cells.
Long preclinical period (up to 9 to 13 years)
marked by the presence of immune markers
when β-cell destruction is thought to occur.
 Hyperglycemia : 80% to 90% of β- cells are
destroyed, till absolute insulin deficiency occurs.
Pathophysiology-Type 1 DM:
Honeymoon Phase: transient remission followed
by established disease with associated risks for
complications and death.
The factors that initiate the autoimmune process
are unknown,
 Mediated by macrophages and T lymphocytes
with circulating autoantibodies to various β-cell
antigens (e.g., islet cell antibody, insulin
antibodies)
Pathophysiology-Type 1 DM
(Cont)
More than 90% of DM cases
Presence of both insulin resistance and relative insulin
deficiency.
Insulin resistance is manifested by increased lipolysis and
free fatty acid production, increased hepatic glucose
production, and decreased skeletal muscle uptake of glucose
 β-Cell dysfunction is progressive and contributes to
worsening blood glucose control over time.
Type 2 DM occurs when a diabetogenic lifestyle (excessive
calories, inadequate exercise, and obesity) is superimposed
upon a susceptible genotype
Pathophysiology-Type2
Pathophysiology-Others
Uncommon (1% to 2% of cases)
Endocrine disorders
Acromegaly,
Cushing’s syndrome),
Gestational diabetes mellitus (GDM),
Diseases of the exocrine pancreas:
Pancreatitis
Medications :
Glucocorticoids
Pentamidine
Niacin
 α- interferon
Patho-physiological changes in a diabetic patient
Patho-physiological changes in a diabetic patient
What are the
classic symptoms of
Diabetes mellitus?
What are the classic symptoms of DM?
Polyphagia
Polyuria
The Classic Symptoms
•Polyphagia (frequently hungry)
•Polyuria (frequently urinating)
•Polydipsia (frequently thirsty)
Polydipsia
What are the other signs & symptoms of DM?
Blurred vision
Fatigue
Weight loss
Poor wound healing (cuts, scrapes, etc.)
Dry mouth
Dry or itchy skin
Impotence (male)
Recurrent infections:
vaginal yeast,
groin rash,
external ear infections (swimmers ear)
Other Signs and symptoms of diabetes mellitus
Clinic
1- polyuria
2-polydipsia
3-polyphagia
4-nocturia
5- weight loss( mostly
in type 1)
6- visual disturbance
7- fatigue
ER
1- acute abdomen
2-nausa and vomiting
(diabetic ketoacidosis )
3-confiusion
(sever hyperosmolar
hyperglycemia
How to evaluate a
patient with DM?
Components of the comprehensive diabetes evaluation
1-Medical history.
2-Physical examination.
3-Laboratory evaluation.
4-Referrals.
Components of the comprehensive diabetes
evaluation:
Age and onset of diabetes
(1)
Eating patterns and nutritional status. Medical history
physical activity.
Presence of common comorbidities.
Psychosocial problems
Dental disease
Previous and current treatment regimens (if any) .
DKA frequency( severity, and cause)
Hypoglycemic eps
History of diabetes-related complications
diabetes-related complications
Short-term
complications
long-term
complications
*Hypoglycaemia
Diabetic ketoacidosis (DKA
*state
hyperglycaemic
* (HHS) Hyperosmolar
.
*
*
*
Microvascular
Retinopathy
Nephropathy
Neuropathy
*
*
*
Macrovascular
Coronary heart disease
Cerebrovascular disease
Peripheral arterial disease
Components of the comprehensive diabetes
evaluation:
* Height, weight, BMI
Blood pressure
Fundoscopic examination
*
Thyroid palpation
Skin examination
*
Comprehensive foot examination
(2)
Physical
examination
Components of the comprehensive diabetes
evaluation:
FBS, 2PP
HbA1C
Fasting lipid profile
Urea and Creatinine
Albumin to Creatinine ratio
TSH in type 1 diabetes
(3)
Laboratory
evaluation
Components of the comprehensive diabetes
evaluation:
Eye care professional .
Family planning for women of
reproductive age.
(4)
Referrals
Dietitian for medical nutrition therapy.
Dentist for comprehensive periodontal
examination
Mental health professional, if needed
How can we
manage diabetes
mellitus ?
Gen. Approach to
Management
Diabetes management is a team work
Individualize management
Set Target goals
Glycaemic goals
BP goals
Lipid goals
Eye Care
Education
we need ….
Physician
Nutrition
Educator
Ophthalmologist
And in need we can consult :
Vascular, Nephrologist, Neurologist
Management of diabetes mellitus
Goals are :
* To confirm the diagnosis .
* To classify the condition .
* To reduce diabetic symptoms .
* To prevent short and long term complications .
* To improve quality of life.
By achieving proper glycemic control
How can we achieve a
proper glycemic
control ?
Management of diabetes mellitus
proper glycemic control
Non –pharmacological
pharmacological
Non –pharmacological
Immunization
Nutrition therapy
is recommended
for all patients.
Psychosocial
Routinely
screen
routine
vaccinations
least 150 min/
week of moderateintensity aerobic
physical activity .
Pharmacological
Treatment?
Two Groups only:
Oral hypoglycemic drugs : Mainly for Type-2
Insulin: Manly for type 1 but it will be needed for
type 2
Metformin OR Salfanylurea
Mono
Metformin + other oral hypoglycemic agent
Dual
Metformin + 2 other oral hypoglycemic agent
triple
Metformin + basal insulin + meal time insulin
Comb
Treatment
- Goals?
• Blood pressure control:
– (ACE inhibitors, ARBs)
– Smoking cessation
• Lipids control:
– Statins
• Glycemic control:
– Diet and exercise
– Diet and oral hypoglycemic drugs
– Diet, oral hypoglycemic drugs and insulin
Indication of Insulin in
Type 2 DM
If HbA1c is ≥ 9 %
After maximum metformin and sulphonylurea, we should
consider adding Insulin and taper the Sulphonylurea
- Self-monitoring of blood glucose (SMBG)
- dose of insulin
- Recognition of hypoglycemia symptoms and
management
- Carrying a card stating name, diagnosis, doses
- How to maintain foot hygiene
Education of patient
Summary
DM is a chronic depilating disease
Management of DM is a team approach
Patient, Physician, Surgeon, Dentists, Dietitian,
Health educator, Ophthalmologist, …. All play
important roles
 The tried of the management is:
Medication
Diet
Exercise
Good control will lead to better outcomes
Other co-morbidities to be tackled well