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Diabetes Mellitus

Delta cell &236(

ecretes O)ATOTATIN

9 cell "" cell &86(

ecretes "ANC*ATIC "OL#""TID

INSULIN

Comosition: ; and < chains =oined by disul$ide bond

!ain determinant of secretion:Blood Glucose

"alf life: 1 minutes

#egradation: Insulinase &liver(

INSULIN; AC$I%N

INC*A:

+lucose upta/e into the cell

+lyco%enesis

Amino acid upta/e into the cell

Lipo%enesis and $at deposition

"otassium upta/e into the cell

DC*A:

+L!CONO+NI

+L#CO+NOL#I

LI"OL#I

#ia&etes !ellitus

- a %roup o$ common metabolic disorders that share the phenotype o$

hyper%lycemia0

Pathohysiology

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Diabetes Mellitus

$'PE ( #!

Ima%e source> bac/%round ima%e:http:www0ari5onatransplant0comima%espancreas?lar%e?@0"+

$'PE ) #!

Ima%e source: http:im%0medscape0comarticle87221lide780pn%

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Diabetes Mellitus

Type 7 D) results $rom the ominous octet &shown in $i%ure above( which in the

end leads to hyper%lycemia0 The succeedin% development o$ the si%ns and symptoms are

similar to that o$ type 2 D) with the e4ception o$ development o$ /etosis0

#! C%!PLICA$I%NS:

Cardio*ascular disease+ Diabetes dramatically increases the ris/ o$ various

cardiovascular problems, includin% coronary artery disease with chest pain &an%ina(,

heart attac/, stro/e and narrowin% o$ arteries &atherosclerosis(0 I$ you have diabetes,

you are more li/ely to have heart disease or stro/e0

Ner*e damage ,neuroathy-+4cess su%ar can in=ure the walls o$ the tiny blood

vessels &capillaries( that nourish your nerves, especially in your le%s0 This can cause

tin%lin%, numbness, burnin% or pain that usually be%ins at the tips o$ the toes or

$in%ers and %radually spreads upward0 Le$t untreated, you could lose all sense o$

$eelin% in the a$$ected limbs0 Dama%e to the nerves related to di%estion can cause

problems with nausea, vomitin%, diarrhea or constipation0 9or men, it may lead to

erectile dys$unction0

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Diabetes Mellitus

.idney damage ,nehroathy-+The /idneys contain millions o$ tiny blood

vessel clusters &%lomeruli( that $ilter waste $rom your blood0 Diabetes can dama%e

this delicate $ilterin% system0 evere dama%e can lead to /idney $ailure or irreversible

end'sta%e /idney disease, which may reuire dialysis or a /idney transplant0

Eye damage ,retinoathy-+Diabetes can dama%e the blood vessels o$ the retina

&diabetic retinopathy(, potentially leadin% to blindness0 Diabetes also increases the

ris/ o$ other serious vision conditions, such as cataracts and %laucoma0

Foot damage+Nerve dama%e in the $eet or poor blood $low to the $eet increases

the ris/ o$ various $oot complications0 Le$t untreated, cuts and blisters can develop

serious in$ections, which o$ten heal poorly0 These in$ections may ultimately reuire

toe, $oot or le% amputation0

S/in conditions+Diabetes may leave you more susceptible to s/in problems,

includin% bacterial and $un%al in$ections0

"earing imairment+earin% problems are more common in people with

diabetes0

Al0heimer1s disease+Type 7 diabetes may increase the ris/ o$ Al5heimerEs

disease0 The poorer your blood su%ar control, the %reater the ris/ appears to be0

Althou%h there are theories as to how these disorders mi%ht be connected, none has

yet been proved0

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Diabetes Mellitus

Ima%e source: arrisonEs "rinciples o$ Internal )edicine 2Fth edition p08F18

Classification:

$ye ( dia&etes mellitus

o &$ormerly insulin dependent diabetes mellitus or uvenile diabetes

mellitus(

o results $rom auto'immune beta'cell destruction, leadin% to absolute insulin

de$iciency0

o Typically but not e4clusively in children0

$ye ) dia&etes mellitus

o &$ormerly non'insulin dependent diabetes mellitus or adult'onset D)(

o results $rom a pro%ressive insulin secretory de$ect on the bac/%round o$

insulin resistance

2estational dia&etes mellitus ,2#!-

o diabetes $irst dia%nosed durin% pre%nancy0

Secondary dia&etes

o %enetic de$ects in beta cell $unction or insulin action

o diabetes o$ the e4ocrine pancreas &pancreatitis, cystic $ibrosis(

o dru%' or chemical'induced diabetes &such as $rom the treatment o$ AID,

a$ter or%an transplantation, %lucocorticoids(

o other endocrine diseases &Cushin%Gs syndrome, hyperthyroidism(

#! $ye ( *s+ #! $ye )

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Diabetes Mellitus

Ima%e source: Diabetes'

!nited'$or'Diabetes'

"hilhttp:spectrum0diabetes=ournals0or%content72@2130$ull

Signs and Symtoms:

polydipsia

polyuria

wei%ht loss

polypha%ia

wea/ness and $ati%ue dry and itchy s/in

dry mouth

poor wound healin%

SC3EENIN2 AN# $ES$IN2 F%3 #IA4E$ES IN AS'!P$%!A$IC

IN#I5I#UALS

All individuals bein% seen at any physicianGs clinic or by any healthcare provider

should be evaluated annually $or ris/ $actors $or type 7 diabetes and pre'diabetes0

Uni*ersal screening using la&oratory tests is not recommendedas it would

identi$y very $ew individuals who are at ris/0

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Diabetes Mellitus

"revious dia%nosis o$ Cardiovascular Disease &Coronary Artery Disease, tro/e,

"eripheral Arteriovascular Disease( or who are at hi%h ris/ $or cardiovascular

disease0

A dia%nosis o$ )etabolic yndrome

N%3!AL 4L%%# IS SU2A3 IS #EFINE# AS:

An 9B 801 mmolL &233 m%dL(, or

J *andomcasual blood %lucose 0 &2K3 m%dL(, or

J 7'hr blood su%ar in the 8'%m O+TT 0 &2K3 m%dL(

#IA2N%SIS %F P3E7#IA4E$ES

The criteria $or pre'diabetes is:

J Impaired 9astin% +lucose

9B o$ 801 mmolL &233 m%dL( up to 278 m%dL or 10H mmolL

J Impaired +lucose Tolerance

de$ined as *andomcasual blood %lucose o$ 0 up to 2203 mmolL &2K3'2HH

m%dL( O* 7'hr blood su%ar in the 8'%m O+TT eual to 0 &2K3 m%dL( up to

2203 mmolL &2HH m%dL(

#IA2N%SIS %F #IA4E$ES

#ia&etes !ellitus criteria for diagnosis:

Plasma glucose>126 mg/dL&03 mmolL( afteran overnight fast

o 9astin% is de$ined as no caloric inta/e $or at least F or hours up to a

ma4imum o$ 2K hours, %3

wo!hour plasma glucose >2"" mg/dl &2202 mmoll( durin% an Oral +lucose

Tolerance Test

o The test should be per$ormed as described by the orld ealth

Or%ani5ation, usin% a %lucose load containin% the euivalent o$ 8 %

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Diabetes Mellitus

anhydrous %lucose dissolved in water a$ter an overni%ht $ast o$ between F

and 2K hours, %3

A random lasma glucose 8)99 mgdl &2202 mmoll(

o in a patient with classic symptoms o$ hyper%lycemia &wei%ht loss,

polyuria, polypha%ia, polydipsia( or with si%ns and symptoms o$

hyper%lycaemic crisis0

Amon% A#)"TO)ATIC individuals with positive results, any o$ the three tests

should be *"ATD within two wee/s $or con$irmation0

creenin% $or possible type 2 D) patients is not recommended due to the

$ollowin% reasons: Low prevalence

Not cost e$$ective Interventions to prevent Type 2 D) have not been proven e$$ective

creenin% $or pre'diabetes and Type 7 D) is recommended amon% asymptomatic

children commencin% at a%e 23 years or at onset o$ puberty, i$ puberty occurs at a

youn%er a%e &ADA( with the $ollowin% ris/ $actors:

Overwei%ht &B)I -F8th percentile $or a%e and se4, wei%ht'$or'hei%ht

-F8th percentile, or wei%ht -2736 o$ ideal $or hei%ht( O*

Obese: B)I -H8th centile or - M7D

"lus any 7 o$ the $ollowin% ris/ $actors

9amily history &especially parents and %randparents( o$ Type 7 D) i%ns o$ insulin resistance &Acanthosis ni%ricans, hypertension,

dyslipidemia, "CO, or small $or %estational a%e birth wei%ht(

)aternal history o$ diabetes or +D) durin% the childGs %estation

APP3%AC" $% PA$IEN$S I$" #IA4E$ES:

The initial evaluation o$ the diabetic patient should include a comprehensive

medical history and physical e4amination0

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Diabetes Mellitus

Ima%e source: Diabetes'!nited'$or'Diabetes'"hilhttp:spectrum0diabetes=ournals0or%content72@2130$ull

C%!P3E"ENSI5E INI$IAL E5ALUA$I%N:

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Diabetes Mellitus


Cardio*ascular 3is/ Assessment

Determinin% the coronary heart disease ris/ $actors &history, B", B)I, C( on

initial consultation or $ollow up helps determine the patientEs ris/ $or $urther

complications and thus, appropriate steps could be done to address these ris/s0

The initial and on%oin% assessment o$ people with diabetes should include wei%ht

and hei%ht measurements and calculation o$ the B)I &/%m7 (, and waist

circum$erence &C( to assess the de%ree o$ abdominal $at0

Ima%e source: Diabetes'

!nited'$or'Diabetes


Foot E*aluation

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Diabetes Mellitus

A diabeticEs ris/ $or developin% a $oot ulcer may be as hi%h as 7860@0 Identi$y ris/

$actors $or developin% $oot complications $rom the history or " $ocusin% on previous

$oot ulceration, neuropathy &loss o$ protective sensation(, $oot de$ormity, vascular

disease0

K *is/ $actors $or diabetic $oot disease include:

"eripheral vascular disease&".D(

"eripheral neuropathy

"revious amputation

"revious ulceration, "resence o$ callus, oint de$ormity

5isualmo&ility ro&lems

*is/ $actors $or ".D are

mo/in%

ypertension

hypercholesterolemia0

ye 4amination

T7D) has an insidious onset and some patients may already have retinopathy at

the time o$ dia%nosis08

It is su%%ested to have a comprehensive evaluation $or retinopathy by an

ophthalmolo%ist upon dia%nosin% diabetes0

!ANA2E!EN$:

Li$estyle therapy alone can be %iven $or @ months $or those with pre'hypertension

with B" 2@3'2@H mm % or DB" F3'FH mm %0

"harmacolo%ic therapy M li$estyle therapy should be started $or those with

hypertension de$ined B" 2K3 mm % or DB" H3 mm %, or pre'hypertension

uncontrolled by li$estyle therapy alone0

NON'"A*)ACOLO+IC T*A"#

o Therapeutic li$estyle chan%e

4ercise and wei%ht loss promotion

- aerobic physical activity at least 283 min per wee/, o$

moderate to vi%orous intensity, spread out @ days over the

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Diabetes Mellitus

wee/ with no more than 7 consecutive days between bouts

o$ activity0 230207 )oderate to vi%orous resistant0 mo/in% cessation

Alcohol abstinence

Daily $oot careo Nutritional therapy

D) diet &TANA!* )TOD(

20 Compute $or the IB

a0 IB P &T' 233( ' Q&T' 233( 4 302R70 CO)"!T 9O* TAa0 TA P IB 4 Activity

4E# 3ES$ )

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Diabetes Mellitus

o Have small servings of protein'rich foods e0%0, $ish, sea$ood, e%%s, lean

meat, s/inless chic/en, low'$at cheese, low'$at yo%hurt, low'$at mil/, nuts

EA$ LEAS$

o Minimise fats, sugars, salt and alcohol e0%0, butter, oil, cream, coconut

mil/ and cream, processed meat, $ried $oods, preserved or processed

$oods, pastries, sweets, biscuits, so$t drin/

The Asian'"aci$ic Type 7 Diabetes "olicy +roup22 recommends the $ollowin%

macronutrient proportions &o$ total ener%y inta/e( :

9at: no more than @36 &saturated $at 236(

Carbohydrate: 83'886 &sucrose 236(

"rotein: 28'736

IDAO "LAT )TOD

Ima

%e

source: Diabetes'!nited'$or'Diabetes'"hilhttp:spectrum0diabetes=ournals0or%content72@2130$ull

"A*)ACOLO+IC T*A"#

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Diabetes Mellitus


Amon% the newly dia%nosed diabetics, classi$y the level o$ severity o$ the diabetes

accordin% to the %lycemic levels, presence o$ symptoms and complications

Those who are asymptomatic with relatively lower levels o$ blood su%ar &bAc

F036, 9B 2K3, *B 733 m%dL( should be advised to underta/e )NT,

physical activity and e4ercise and wei%ht reduction, with an option o$ startin%

pharmacolo%ic therapy &met$ormin(0

I$ %lycemic tar%ets are not reached within @ months, then

pharmacolo%ic treatment will be started0

Those who have hi%her blood su%ars, or who are symptomatic

should be started ri%ht away on one or more pharmacolo%ic a%ents

as applicable since diet and li$estyle chan%es are unli/ely to

achieve the tar%et values0

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Diabetes Mellitus


The $ollowin% patients must ideally be re$erred to internists or diabetes specialists

&endocrinolo%ists or diabetolo%ists(:

20 individuals with Type 2 diabetes

70 patients who have moderate to severe hyper%lycemia

@0 who have co'morbid conditions e0%0, in$ections, acute cardiovascular events such

as con%estive heart $ailure or acute myocardial in$arction

K0 si%ni$icant hepatic and renal impairment

80 women with diabetes who are pre%nant

!ANA2E!EN$ %F #IA4E$ES

I+ INSULIN $"E3AP'

Common side e$$ects:

ypo%lycemia

ei%ht %ain

> !A?%3 C%!P%NEN$S %F E@%2EN%US INSULIN $"E3AP'

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Diabetes Mellitus

4ASAL

INSULIN

3euired to regulate meta&olic rocesses e*en in the

a&sence of meals

Usual :&asal insulinB: gi*en as intermediate or long7acting

insulin

Intermediate7acting insulin usually gi*en in ortions of )>

in am and (> in m

4%LUS

INSULIN

*euired to cover %lycemic e4cursions $ollowin% a meal

!sual Sbolus insulin: %iven as short or rapid'actin% insulin

*apid'actin% insulin %iven within 28'73 min or immediately

be$ore meals

hort'actin% insulin %iven within @3'K8 in be$ore meals

C%33EC$I%NAL

INSULIN

upplemental doses o$ short or rapid'actin% insulin %iven tocorrect elevations in blood %lucose that occurs despite the use o$

basal or bolus insulin0

INI$IA$I%N %F INSULIN $"E3AP' IN $(#!

Calculate total insulin reirement; usually 9+=7( unit /g day =9 of comuted *alue gi*en as a &asal insulin

INI$IA$I%N %F INSULIN $"E3AP' IN $)#!

4ASAL

INSULIN

Calculate dose at 9+) units/gday for insulin7naD*e

atients

4%LUS

INSULIN

Initiated i$ unable to achieve tar%et a2c with basal insulin

alone

tart with K units be$ore each meal or valculate each dose at

302 units/%

4ASAL7

4%LUS

INSULIN

Calculate units at 30@'308 units/%day

836 o$ dose %iven as basal insulin

Nph: 7@ pre'brea/$ast, 2@ pre'dinner

+lar%ine or detemir: %iven at bedtime

836 o$ dose %iven as bolus insulin in eual divided doses

pre'meals

Insulin tyes

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Diabetes Mellitus

II+ C%!!%N "'P%2L'CE!IC A2EN$S

$ye of drug Su&tyes Examles 2en+ mech of

action

Common side

effects

Insulin

secretagogues

Sulfonylureas 2licli0ide

2li&enclamid

e

2lii0ide

2limeiride

Increase

insulin

secretion

"yoglycemia

eight gain

Non7

sulfunylure

Insulin

sensiti0er

4iguanides !etformin #ecrease

heatic

glucose

roduction

Imro*es

eriheral

glucose

utili0ation

eight loss

Lactic acidosis

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Diabetes Mellitus

$hia0olidines 3osiglita0one

Pioglita0one

#ecrease

insulin

resistanceImro*es

eriheral

glucose

utili0ation

Edema

eight gain

%steoorosis

Anemia

Intestinal

absorption

inhibitor

Alha

glucosidase

inhi&itor

Acar&ose

!iglitol

Inhi&it

intestinal

a&sortion of

sugars

eight loss

#iarrhea

Flatulence

Liase

inhi&itors

%rlistat

III+#3U2S AN# (oA3EAS %F C%N$3%L

2oal of treatment &ased on a(c

I$ BA2C is 6 Control ""+ $irst

I$ BA2C is 'H6 Control both 9"+ and ""+

I$ BA2C is H6 Control 9"+ $irst

Com&ination $heray

hen %lycemic tar%ets are not achieved with one dru% %iven at the ma4imum

e$$ective dose &optimal dose or hal$ ma4imum(, another dru% $rom another

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Diabetes Mellitus

pharmacolo%ic class should be added rather than increasin% the $irst dru% to its ma4imum

dose0

P3EFE33E# #3U2

Initiate treatment with met$ormin unless with contraindications or intolerant o$ its

ADGs such as the development o$ diarrhea, severe nausea or abdominal pain0

hen optimi5ation o$ therapy is needed, then a second dru% can be chosen $rom

the table accordin% to the $ollowin% considerations: amount o$ bA2c lowerin%,

hypo%lycemia ris/, wei%ht %ain, pt pro$ile &dosin% comple4ity, renal and hepatic

problems, other contraindications and a%e(0

C%N$3%L AN# !%NI$%3IN2 %F 4L%%# SU2A3

The ideal tar%et is the bA2c> bA2c should be measured usin% a National

+lycosylated emo%lobin tandardi5ation "ro%ram certi$ied method and results should

be DCCT'ali%ned0

)easure the individualGs bA2c levels at @U1' monthly intervals tailored

accordin% to individual needs and access to laboratory $acilities0

bA2c monitorin% may be inaccurate invalid in the $ollowin% conditions because o$

disturbed erythrocyte turnover or abnormal haemo%lobin type:

"re%nancy

emolysis

blood loss

hemo%lobinopathies

Alternative measures where bA2c methods are invalid:

uality'controlled plasma %lucose pro$iles

total %lycated hemo%lobin estimation

$ructosamine estimation0

Other )ethods 9or )onitorin% +lycemic Control:

9B

*B

Capillary Testin%

Colorimetric %lucose strips

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Diabetes Mellitus

!%NI$%3IN2 3ESP%NSE

SULF%N'LU3EAS

(7) ee/s

9"+ at 7 wee/s

BA2C at @ months

!E2LI$INI#ES 9"+ at 7 wee/s

BA2C at @ months

""+ at initiation

!E$F%3!IN)7> ee/s

9"+ at 7 wee/s

BA2C at @ months

ACA34%SE )7 ee/s BA2C at @ months ""+ at initiation

$"IAG%LI#INES

(7) months

9"+ at K wee/s

BA2C at @'1

months

#PP7I5 Inhi&itors

) ee/s

9"+ at 7 wee/s

BA2C at @ months

""+ at initiation

$A32E$S F%3 2L'CE!IC C%N$3%L

In order to achieve A2C o$ 036, people with diabetes should aim $or:

An 9"+ or preprandial "+ tar%et o$ K03 to 03 mmolL &7 to 271 m%dl(

A 7'hour postprandial "+ tar%et o$ 803 to 2303 mmolL &H3 to 2F3 m%dL(

o Alternatively, capilary blood %lucose tar%ets can be: 9B H3'2@3 m%dL

&ADA(, ""B+

In order to achieve a tar%et A2c:

9astin%: 103 mmoldL or 223 m% dL

"ost'prandial: F03 mmolL or 2K8 m%dL

A tar%et o$ 1086 may be optimal $or certain types o$ patients such as those with short

duration o$ diabetes, lon% li$e e4pectancy, no si%ni$icant active cardiovascular disease, no

serious co'morbid ris/ $actors and at low ris/ $or cardiovascular events that may be

tri%%ered by hypo%lycemia0

Tar%ets $or optimal blood pressure control:

The %oal B" $or most diabetic patients is ,2K3F3 mm%

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Diabetes Mellitus

P3E5EN$I%N

Therapeutic li$estyle chan%e0 "roper diet and e4ercise

mo/in% cessation

Alcohol abstinence

3eferences:

arrisonEs "rinciples o$ Internal )edicine 2Fth edition

Diabetes'!nited'$or'Diabetes'


I) "latinum 7nddition 7328

https:www0youtube0comwatchVvPA=WvK2i!!

https:www0youtube0comwatchVvPyIc7X9NLhmF

http:www0webmd0comdiabetes%uideunderstandin%'diabetes'symptomsV

pa%eP7 http:mediacenter0novomedlin/0comvthe'ominous'octet'core'de$ects'in'type'7'

diabetes http:emedicine0medscape0comarticle22@H'overviewYa1

http:www0mayoclinic0or%diseases'

conditionsdiabetesbasicscomplicationscon'733@@3H2

http:www0ari5onatransplant0comima%espancreas?lar%e?@0"+

http:im%0medscape0comarticle87221lide780pn%

http:www0slideshare0netisiptanmedical'nutrition'therapy'in'diabetes

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