1. Diabetes Mellitus Overview

2. Definition Disease of abnormal carbohydrate metabolism characterized by hyperglycemia Caused by: –Impairment in insulin secretion and/or –Peripheral resistance to insulin

3. ??? True or False Diabetes insipidus is the opposite of diabetes mellitus, in other words, a problem of low blood sugar.

4. False Diabetes insipidus –Disorder involving the secretion or response to ADH (antidiuretic hormone) –Causes high-volume urine output and hypernatremia –Not a glucose problem

5. Diabetes Mellitus Over 7% of U.S. population 14% of health care expenditures 132 billion dollars (2002) Associated with: –Higher psychiatric illness –Decreased work productivity –Increased absenteeism

6. Diabetes Mellitus Type 1: destruction of pancreatic beta cells leading to insulin deficiency (10%) Type 2: insulin resistance with varying degrees of insulin deficiency (80%) Gestational: insulin resistance created by anti-insulin hormones secreted by placenta during pregnancy Other causes: drugs, infections

7. Type 1 DM Autoimmune destruction of insulin- producing cells in pancreas –Islet cell autoantibodies –Glutamic acid decarboxylase antibodies –Anti-insulin antibodies –Associated with other autoimmune diseases Genetically susceptible Triggered by environmental agent

9. ??? Diabetes mellitus damages: A.Eyes B.Kidney C.Nerves D.Heart E.Brain

10. Complications Microvascular –Nephropathy –Neuropathy –Retinopathy Macrovascular –Coronary artery disease –Peripheral vascular disease –Stroke

11. Diabetic nephropathy Microalbuminuria > Macroalbuminuria > Elevated creatinine > End stage renal disease > Dialysis Asymptomatic

12. Diabetic neuropathy 18% have evidence of nerve damage at diagnosis Usually symmetrical, affecting lower extremities first Stocking-glove syndrome Impaired sensation (pain, light touch, temperature, vibration, proprioception) Can feel numb or painful

13. Diabetic neuropathy Major risk factor for foot ulcers Autonomic neuropathy –Postural hypotension –Gastroparesis –Enteropathy (constipation/diarrhea)

15. Diabetic retinopathy Most common cause of blindness in middle-aged people Blindness 25x higher in diabetics Asymptomatic until late stages 80% of type 2’s have retinopathy at 20y Mechanisms –Impaired blood flow –Accumulation of sorbitol in retina

19. Diabetes and the Heart Diabetics have: –Higher rate of heart disease –Greater coronary ischemia –Higher chance of MI and silent MI CHD risk equivalent –Aggressive LDL goal

20. ??? Per ADA, DM (type 2) screening should begin at what age? A.25 B.35 C.45

21. Screening Start at age 45; if normal repeat every 3 years Screen earlier or more frequently if overweight with additional risk factor –Inactive –Family history (1 st degree relative) –HTN –IFG or IGT –Vascular disease

22. Diagnosis American Diabetes Association Fasting plasma glucose Random glucose with symptoms Oral glucose tolerance test Should be confirmed with repeat testing on different day

23. Diagnosis Fasting plasma glucose Fasting = no caloric intake for 8 hours Greater than or equal to 126 mg/dl

24. Diagnosis Random glucose with symptoms Glucose greater than or equal to 200 mg/dl at any time Classic symptoms: polydipsia, polyuria, weight loss

25. Diagnosis Oral glucose tolerance test Glucose greater than or equal to 200 mg/dl two hours after 75g glucose load

26. Treatment Nonpharmacologic (lifestyle) –Proper diet –Exercise –Weight loss Benefits greater to type 2’s

27. Drug treatment Insulin - Initial treatment in type 1’s - In type 2’s, more commonly used after oral agents fail Multiple daily injections –Lantus + Humalog Continuous infusion Adjustments based on HgbA1c and daily glucose checks

28. Drug treatment MetforminSulfonylureasMeglitinidesThiazolidinediones Alpha-glucosidase inhibitors

29. Metformin Decreases liver glucose production Improves insulin sensitivity Modest weight reduction Avoid in renal insufficiency Avoid before IV contrast load or surgical procedure (lactic acidosis) Start 500mg once daily with dinner

30. ??? Metformin should be held ___ hours before IV contrast studies. A.8 B.24 C.48 D.96

31. Sulfonylureas Increase insulin release Oldest class of oral agent Higher rate of hypoglycemic complications Starting doses –Glipizide 5mg daily –Glyburide 2.5 to 5mg daily –Glimeperide 1 to 2 mg daily

32. Meglitinides Increase insulin release Short-acting, expensive Taken with meals Starlix, Prandin

33. Thiazolidinediones Increases insulin sensitivity Less effective than metformin and sulfonylureas as monotherapy Causes weight gain, fluid retention Avoid in heart failure

34. Alpha-glucosidase inhibitors Modifies intestinal absorption of carbohydrate Less potent than oral agents (0.5-1% A1c reduction) Main side effects: gas, diarrhea Take with meals

35. Persistent hyperglycemia Combination therapy (type 2’s) –2 or 3 drugs together –2 orals then add insulin if needed –No need for sulfonylurea and insulin together Exenatide (Byetta) –Twice daily subcutaneous injection –Promotes weight loss –GI side effects –Overweight patient gaining weight on orals

36. ??? True or False Insulin can be inhaled.

38. Persistent hyperglycemia Inhaled insulin –Rapid, similar to lispro insulin –Taken with meals –Excludes patients with respiratory disorders –Long-term effects on lungs not defined

39. Long-term care HgbA1c (goal < 7%) 7% = 150 (1% change = 30) Glucose targets (frequency 2-4x day) –Preprandial (90 to 130) –Postprandial (<180)

40. Long-term care Routine eye exams –Dilated and comprehensive exam shortly after diagnosis –Annual exams thereafter –Ophthalmologist or optometrist recommended

41. Long-term care Routine foot exams –Detect or monitor vascular/neurologic complications –Visual inspection of feet at each routine visit –Comprehensive exam yearly Pulses Monofilament test

43. Long-term care Screen or treat microalbuminuria –Dipstick is insensitive –Spot urine collection measuring albumin to creatinine ratio > 30mg/g abnormal > 30mg/g abnormal ACE-inhibitor or ARB prevents progression of nephropathy

44. Long-term care Aggressively treat cardiac risk factors –Smoking –Hypertension (< 130/80) –Dyslipidemia (LDL < 100) Aspirin (81mg) for 1° CHD prevention for anyone with one risk factor

45. Acute complications Diabetic ketoacidosis –Metabolic acidosis is main concern Nonketotic hyperglycemia –Glucose often > 1000 –Neurologic abnormalities frequent Precipitating factors: MI, pancreatitis, trauma, any stress to body Treatment requires IV insulin, hydration, electrolyte replacement

46. Questions?