Diabetes Mellitus Cases Prince Sattam Bin AbdulAziz University College Of Pharmacy Diabetes Mellitus Cases

Case 1 R.P. is a 43-year-old African American woman visiting the drop-in clinic to obtain a routine physical examination for her new job. Her past medical history is significant for GDM. She was told during her two pregnancies (last child born 3 years ago) that she had “borderline diabetes,” which resolved each time after giving birth. Her family history is significant for type 2 diabetes (mother, maternal grandmother, older first cousin), hypertension, and CVD. She denies tobacco or alcohol use. She states she tries to walk 15 minutes twice a week.

Physical examination is significant for moderate central obesity (5 feet 4 inches; 160 lbs; BMI, 30.2 kg/m2) and BP 145/85 mmHg. R.P. denies any symptoms of polyphagia, polyuria, or lethargy. Upon checking her electronic medical record, she has documented hypertension and an FPG value of 119 mg/dL, measured 2 months prior. BMI; below 18.5  underweight. BMI; 18.5 to 24.9  healthy. BMI of 25 to 29.9 overweight. BMI; 30 or higher obese.

What features of R.P.’s history and examination are consistent with an increased risk of developing type 2 diabetes?

Increased risk of developing type 2 diabetes? 1- Age 2- Ethnicity 3- Weight 4- Family history of diabetes 5- History of GDM 6- Documented IFG. 7- Hypertension

You’re more at risk of Type 2 diabetes if you’re overweight, especially if you’re large around the middle. You’re more at risk if you’ve ever had high blood pressure. Type 2 diabetes is two to four times more likely in people of South Asian descent and African-Carribean or Black African descent.

You’re two to six times more likely to get Type 2 diabetes if you have a parent, brother, sister or child with diabetes. Your risk increases with age. You’re more at risk if you’re white and over 40 or over 25 if you’re African-Caribbean, Black African, or South Asian.

A. Patient education ..………………………………………………………….... diabetes. 2. The physician orders another FPG for R.P., which comes back at 122 mg/dL. How should R.P. be managed at this time? A. Patient education ..………………………………………………………….... diabetes. B. lifestyle modifications (MNT, physical activity)………. for About risk factors of developing lose weight, improve her cardiovascular health decrease her risk for developing type 2 diabetes. Medical Nutrition Therapy= MNT

Treatment There are three major components to the treatment of diabetes: 1- Diet 2- Drugs (insulin and oral hypoglycemic agents, and other antihyperglycemic agents) 3- Exercise.

Q. What are the three major components to the treatment diabetes? Q. How to manage patient with increased risk of developing D.M?

Gestational diabetes is high blood sugar that develops during pregnancy and usually disappears after giving birth. It can occur at any stage of pregnancy, but is more common in the second half. It occurs if your body cannot produce enough insulin – a hormone that helps control blood sugar levels – to meet the extra needs in pregnancy. Gestational diabetes can cause problems for you and your baby during and after birth. But the risk of these problems happening can be reduced if it's detected and well managed.

What are the symptoms of gestational diabetes? Symptoms of diabetes can include: passing urine more often increased thirst extreme tiredness. However, in gestational diabetes these symptoms are less common – and they often occur during pregnancy anyway

Continuous high blood glucose levels can lead to: Needing to have your labour induced. Having a caesarean section. Having a larger than normal baby (macrosomia), which could result in a more painful birth and possible stress for the baby. Your newborn having low blood glucose levels (neonatal hypoglycaemia). Perinatal death – your baby dying at around the time of the birth. Your baby having a higher risk of being overweight or obese and/or developing Type 2 diabetes in later life. As your child grows, managing their weight, eating healthily and being physically active will reduce this risk.

Case 2 A.H., a slender, 18-year-old woman who was recently discharged from the hospital for severe dehydration and mild ketoacidosis is referred to the Diabetes Clinic (no records available). A fasting and a random plasma glucose ordered subsequently were 190 mg/dL (normal, 70–110) and 250mg/dL (normal, 140 to<200). 4weeks before she was hospitalized, A.H. she remembers that she had symptoms of polydipsia, nocturia (six times a night), fatigue, and a 12-lb weight loss over this period, which she attributed to the anxiety associated with her move away from home and adjustment to her new environment.

Medical history Recurrent upper respiratory infections Three cases of vaginal moniliasis over the past 6 months. Family history is negative for diabetes, and she takes no medications. Physical examination is within normal limits. (weight 50 kg and is 5 feet 4 inches tall) Laboratory results are as follows: FPG, 280 mg/dL (normal, <100); HbA1c, 14%(normal, 4%–6%); and trace urine ketones as measured by Keto-Diastix (normal, negative).

A,H diagnosis is consistent with ? D.M type I D.M type 2 Impaired fasting blood glucose (IFG) None of the above

Define Diabetes ? Compare between type I DM and Type 2 DM ? Diagnosis of DM?

Subjective , Objective , Assessment for this case ?

This patient has ……………. D.M type I 1- She has classic symptoms of the disease (polyuria, polydipsia, weight loss, glucosuria, fatigue, recurrent infections) 2-A random plasma glucose above 200 mg/dL 3- FPG of 126 mg/dL or higher on at least two occasions4 4- Elevated HbA1c 5- Features of A.H.’s history that are consistent with type 1 diabetes, in particular, include the relatively acute onset of symptoms in association with a major life event (moving away from home), 6- ketones in the urine, 7- negative family history 8- a relatively young age at onset 9- vaginal infection.and URTI This patient has ……………. D.M type I

A.H. will be started on insulin therapy on this visit. What are the goals of therapy? A. Prevent the onset of Chronic complications Acute complications Microvascular: Retinopathy, nephropathy, and neuropathy Macrovascular: Cardiovascular, cerebrovascular, and peripheral vascular diseases The goal of diabetes management is the prevention of acute and chronic complications The ADA recommends an HbA1c goal of less than 7% for patients in general In summary, A.H. is a patient newly diagnosed with type 1 diabetes who has not yet developed any signs or symptoms of long-term complications. Therefore, she is an ideal candidate for basal-bolus insulin therapy and, if she is willing and motivated, normoglycemia with rare hypoglycemic reactions is a reasonable long-term goal. This goal should be achieved gradually over several months with insulin therapy, diet, education, and strong clinical support. A desirable goal is an HbA1c value as close to the normal range as possible with rare hypoglycemic reactions Hypoglycemia, diabetic ketoacidosis (DKA) Hyperglycemic hyperosmolar nonketotic syndrome

Hyperosmolar Hyperglycaemic State (HHS) occurs in people with Type 2 diabetes who experience very high blood glucose levels (often over 40mmol/l). It can develop over a course of weeks through a combination of illness (e.g.infection) and dehydration. Stopping diabetes medication during illness (e.g. Because of swallowing difficulties or nausea) can contribute, but blood glucose often rises despite the usual diabetes medication due to the effect of other hormones the body produces during illness.

Consistently high blood glucose levels can lead to a condition called diabetic ketoacidosis (DKA). This happens when a severe lack of insulin means the body cannot use glucose for energy, and the body starts to break down other body tissue as an alternative energy source. Ketones are the by-product of this process. Ketones are poisonous chemicals which build up and, if left unchecked, will cause the body to become acidic – hence the name 'acidosis'.

A.H. will be started on insulin therapy on this visit. What are the goals of therapy for D.M? B. Glycemic therapy goals HgA1c less than 7.0%. (Note: The ACE/AACE guidelines recommend 6.5% or less for selected patient those with short duration of diabetes, long life expectancy, and no significant CVD.) II. Less stringent HbA1C goals (such as < 8%) The goal of diabetes management is the prevention of acute and chronic complications The ADA recommends an HbA1c goal of less than 7% for patients in general In summary, A.H. is a patient newly diagnosed with type 1 diabetes who has not yet developed any signs or symptoms of long-term complications. Therefore, she is an ideal candidate for basal-bolus insulin therapy and, if she is willing and motivated, normoglycemia with rare hypoglycemic reactions is a reasonable long-term goal. This goal should be achieved gradually over several months with insulin therapy, diet, education, and strong clinical support. A desirable goal is an HbA1c value as close to the normal range as possible with rare hypoglycemic reactions Patient with of severe hypoglycemia, limited life expectancy, advanced microvascular macrovascular complications, extensive comorbid conditions

A.H. will be started on insulin therapy on this visit. What are the goals of therapy for D.M? B. Glycemic therapy goals III. FPG 70–130 mg/dL. Frequency of monitoring very dependent on regimen, type of DM) IV . Peak postprandial glucose (1–2 hours after a meal) less than 180 mg/dL C. Non-glycemic therapy goals The goal of diabetes management is the prevention of acute and chronic complications The ADA recommends an HbA1c goal of less than 7% for patients in general In summary, A.H. is a patient newly diagnosed with type 1 diabetes who has not yet developed any signs or symptoms of long-term complications. Therefore, she is an ideal candidate for basal-bolus insulin therapy and, if she is willing and motivated, normoglycemia with rare hypoglycemic reactions is a reasonable long-term goal. This goal should be achieved gradually over several months with insulin therapy, diet, education, and strong clinical support. A desirable goal is an HbA1c value as close to the normal range as possible with rare hypoglycemic reactions BP goal of < 140/ 80 mHg. ( Updated 2013 in ADA guidelines ) BP goal < 130/80 mmHg in young patient with no burden LDL cholesterol < 100 mg/dL HDL cholesterol >50 mg/dL, Triglycerides <150 mg/dL),

Mention chronic complication of D.M ? Mention acute complications of D.M ? What are the glycemic control target ? HbA1c goals in patient with diabetes ? Blood pressure goals in patient with D.M ? Lipid profile targets for patient with D.M ?

Insulin Treatment Insulin is a hormone made in your pancreas, which lies just behind your stomach. It helps our bodies use glucose for energy.  Everyone with Type 1 diabetes and some people with Type 2 diabetes need to take insulin – either by injection or a pump – to control their blood glucose levels (also called blood sugar levels). 

Rapid-acting insulin (Lispro) reaches the blood within 15 minutes after injection. It peaks 30 to 90 minutes later and may last as long as 5 hours. Short-acting (regular) insulin usually reaches the blood within 30 minutes after injection. It peaks 2 to 4 hours later and stays in the blood for about 4 to 8 hours. Intermediate acting (NPH and lente) insulins reach the blood 2 to 6 hours after injection. They peak 4 to 14 hours later and stay in the blood for about 14 to 20 hours. Long acting (ultralente) insulin takes 6 to 14 hours to start working. It has no peak or a very small peak 10 to 16 hours after injection. It stays in the blood between 20 and 24 hours.

Diagnosing Diabetes There are several ways to diagnose diabetes. Each way usually needs to be repeated on a second day to diagnose diabetes.

A1C The A1C is a test that measures a person's average blood glucose level over the past 2 to 3 months. The advantages of being diagnosed this way are that you don't have to fast or drink anything Diabetes is diagnosed at an A1C of greater than or equal to 6.5%

Fasting Plasma Glucose (FPG) This test checks your fasting blood glucose levels. Fasting means after not having anything to eat or drink (except water) for at least 8 hours before the test. This test is usually done first thing in the morning, before breakfast. Diabetes is diagnosed at fasting blood glucose of greater than or equal to 126 mg/dl

Oral Glucose Tolerance Test (also called the OGTT) The OGTT is a two-hour test that checks your blood glucose levels before and 2 hours after you drink a special sweet drink. It tells the doctor how your body processes glucose. Diabetes is diagnosed at 2 hour blood glucose of greater than or equal to 200 mg/dl

Random (also called Casual) Plasma Glucose Test This test is a blood check at any time of the day when you have severe diabetes symptoms. Diabetes is diagnosed at blood glucose of greater than or equal to 200 mg/dl

Type 1 diabetes Type 1 diabetes is an autoimmune condition where the body attacks and destroys insulin-producing cells, meaning no insulin is produced. This causes glucose to quickly rise in the blood. Nobody knows exactly why this happens, but science tells us it’s got nothing to do with diet or lifestyle. About 10 per cent of people with diabetes have Type 1.

Type 2 diabetes In Type 2 diabetes, the body doesn’t make enough insulin, or the insulin it makes doesn’t work properly, meaning glucose builds up in the blood. Type 2 diabetes is caused by a complex interplay of genetic and environmental factors. Up to 58 per cent of Type 2 diabetes cases can be delayed or prevented through a healthy lifestyle. About 90 per cent of people with diabetes have Type 2.

Common differences between type 1 and type 2 diabetes Usually diagnosed in over 30 year olds Often diagnosed in childhood Often associated with excess body weight Not associated with excess body weight Often associated with high blood pressure and/or cholesterol levels at diagnosis Often associated with higher than normal ketone levels at diagnosis Is usually treated initially without medication or with tablets Treated with insulin injections or insulin pump Sometimes possible to come off diabetes medication Cannot be controlled without taking insulin

Common Symptoms Hunger and fatigue Peeing more often and being thirstier Dry mouth and itchy skin Blurred vision Unplanned weight loss

Diabetes treatments There are a number of treatments available to help you manage and control your diabetes. Everybody is different, so treatment will vary depending on your own individual needs. If you have Type 1 diabetes, you will need to treat the condition with insulin, whereas if you have Type 2, you may initially be able to manage your condition with diet and exercise.

There are a number of different medications available to people with diabetes, all of which work in a variety of different ways.  Not all treatments are suitable for everyone, so don’t be disheartened if you find yourself needing to change or stop certain medications. Your GP or healthcare professional can help you find a medication that’s best for your individual needs.

Diabetes Drugs Biguanide (Metformin) Sulphonylureas (Glimepiride ) Alpha glucosidase inhibitor (arcabose) Prandial glucose regulators - Meglitinides (Repaglinide ) Thiazolidinediones (glitazones) DPP-4 inhibitors (gliptins) such as Sitagliptine SGLT2 inhibitors such as Canaglifozine Glucagon-like peptide-1 (GLP-1) agonist Such as Exenatide