Diabetes mellitus

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Diabetes mellitus

  1. 1. DIABETES<br />MELLITUS<br />BY<br />TIKAL KANSARA<br />BARODA MEDICAL COLLEGE (BMC)<br />
  2. 2. DIABETES MELLITUS<br />Diabetes Mellitus (DM) refers to a group of common metabolic disorders that share the common phenotye of hyperglycemia<br />Depending on etiology, factors contributing to hyperglycemia includes:<br />Reduced insulin secretion<br />Decreased glucose utilization<br />Increased glucose production<br />
  3. 3. CLASSIFICATION<br />Type I DM <br />Type II DM<br />Other specific types:<br />Genetic deficiency of B- cell functions<br />Hepatocyte nuclear transcriptioon factor 4 alfa (MODY 1)<br />Glucokinase (MODY 2)<br />HNF – 1alfa (MODY 3)<br />Insulin promoter factor 1 (MODY 4)<br />HNF 1beta (MODY 5)<br />neuroD1 (MODY 6)<br />
  4. 4. Genetic defects in insulin action<br />Type A insulin resistance<br />Leprechaunism<br />Lipodystrophy syndromes<br />Dieases of exocrine pancreas: pancreatitis, pancreatectomy, neoplasia, cystic fibrosis, hemochromatosis<br />Endocrinopathies: Acromegaly, Cushing Syndrome, pheochromocytoma, hyperthyroidism<br />Drug or chemical induced: pentamitice, nicotinic acid, glucocorticoids, thyroid hormones, phenytion, protease inhibitors, clozapine<br />Infections: congenital rubella, CMV, Coxsachie<br />Uncommon forms: anti-insulin receptor antibodies<br />Other genetic conditions associated with Diabetes: Down Syndrome, Klinefelter Syndrome, Turner’s Syndrome, Friedrich’s Ataxia, Huntington’s Chorea, Porphyria<br />Gestational Diabetes Mellitus <br />
  5. 5. SPECTRUM OF GLUCOSE HOMEOSTASIS & DM<br />
  6. 6. NORMAL PHYSIOLOGY OF INSULIN ACTION<br />http://1.bp.blogspot.com/_N-RTY7s9S4A/SJwltA7yq7I/AAAAAAAAAUg/-rtv3wsulaE/s400/Insulin.jpg<br />
  7. 7. RISK FACTORS FOR DIABETES MELLITUS<br />Family history of diabetes (parent or sibling)<br />Obesity (BMI > 25)<br />Habitual physical inactivity<br />Race/ethinicity<br />Previously identified IFG or IGT<br />History of GDM or delivery of baby > 4 kg<br />Hypertension ( BP > 140/90 mmHg )<br />HDL cholestrol level < 35 mg/dl &/or a TG level > 250 mg/dl<br />PCOD or Acanthosisnigricans<br />History of vascular disease<br />
  8. 8. PATHOGENESIS OF DM 1<br />http://www.discoverymedicine.com/Didier-Hober/files/2010/08/discovery_medicine_hober_no51_figure_5.jpg<br />
  9. 9. http://ocw.tufts.edu/Content/14/lecturenotes/265878/133132_medium.jpg<br />
  10. 10. http://ocw.tufts.edu/data/51/673764/674515_xlarge.jpg<br />
  11. 11. http://img.medscape.com/slide/migrated/editorial/cmecircle/2001/145/prato/slide02.gif<br />
  12. 12. METABOLIC ABNORMALITIES OF DM TYPE DEUX<br />
  13. 13. http://4.bp.blogspot.com/_l2LRboVHKr4/TMZ9sVGyxZI/AAAAAAAAAH4/-B6JocyPDOQ/s320/xxx.....111diabetes-symptoms.jpg<br />
  14. 14. MAIN INSULIN RESISTANCE SYNDROMES<br />The main insulin resistance syndromes include<br />The Metabolic Syndrome (Syndrome X)<br />Polycystic Ovary Syndrome (PCOS)<br />
  15. 15. METABOLIC SYNDROME<br />http://professional.diabetes.org/content/multimedia/images/lge/lge_qhscw16-metabolic%20syndrome-4%20copia.gif<br />
  16. 16. http://kardiol.com/wp-content/uploads/2011/01/metabolic-syndrome-2.jpg<br />
  17. 17.
  18. 18. DIABETIC KETOACIDOSIS<br />SYMPTOMS<br /><ul><li>Nausea/Vomitting
  19. 19. Thirst/Polyuria
  20. 20. Abdominal Pain
  21. 21. Shortness Of Breath</li></ul>PHYSICAL SIGNS<br /><ul><li>Tachycardia
  22. 22. Dehydration/Hypotension
  23. 23. Tachpnea/Kussmaul Respiration/Respiratory Distress
  24. 24. Abdominal Tenderness
  25. 25. Lethargy/Obtundation/Cerebral Oedema/Possibly Coma</li></li></ul><li>http://www.bestsyndication.net/images_com/2010/02_february/04/20100204_diabetic_ketoacidosis-lg01.jpg<br />
  26. 26. PATHOPHYSIOLOGY OF DK<br />
  27. 27. COMPARATIVE LABORATORY IN DK & HHS<br />
  28. 28. http://pmj.bmj.com/content/80/943/253/F1.large.jpg<br />
  29. 29. TREATMENT OF DK<br />INITIAL EVALUATION<br /><ul><li>History & physical examination
  30. 30. Laboratory Tests: ABG, CBC, Urinalysis, RBS, BUN, creatinine.
  31. 31. ECG & CXR
  32. 32. Start IV fluids … 1 L of 0.9% NaCl /hr initially (15 – 20 ml/kg/hr)</li></ul>DIAGNOSTIC CRITERIA<br /><ul><li>RBS > 250 mg/dl
  33. 33. pH < 7.3
  34. 34. S. bicarbonate < 15 mEq/L
  35. 35. Moderate ketonuria & ketonemia</li></li></ul><li>FLUID REPLACEMENT<br />2 – 3 L of 0.9% NaCl over first 1 – 3 hrs (10-15 ml/kg/hr);<br />Followed by: 0.45% NaCl @ 150 – 300 ml/hr<br />Change to 5% glucose & 0.45% NaCl when glucose level reaches 250 mg/dl<br />
  36. 36. SHORT ACTING INSULIN<br />IV (0.1 U/kg) or IM (0.3 U/kg) stat<br />Then, 0.1 U/kg/hr continuous infusion; increase to 2 to 3 times, if no response by 2 – 4 hrs<br />If initial potassium < 3.3 mEq/L, do not administer insulin till potassium corrected to > 3.3 mEq/L<br />
  37. 37. ELECTROLYTE CORECTIONS<br />POTASSIUM<br /><ul><li>10 mEq/L when K+ < 5.5 mEq/L, ECG normal, urine flow & creatinine documented;
  38. 38. 40 – 80 mEq/L, when initial K+ < 3.5 mEq/L or bicarbonate given</li></ul>BICARBONATE<br /><ul><li>If pH = 6.9 – 7.0 after initial hydration, HCO3 50 mEq/L in 200 ml sterile water with 10 mEq/L KCl
  39. 39. If pH < 6.9, 100 mEq/L HCO3 with 20 mEq/L KCl over 2 hrs in 400 ml sterile water</li></li></ul><li>Monitor glucose, BP, pulse, respiratory rate, mental status, fluid intake & output every 1 – 4 hrs. <br />
  40. 40. CHRONIC COMPLICATIONS OF DM<br />MICROVASCULAR<br />Eye disease<br />Retinopathy<br />Macular oedema<br />Neuropathy<br />Sensory<br />Motor<br />Autonomic<br />Nephropath<br />
  41. 41. MACROVASCULAR<br />Coronary artery disease<br />Peripheral artery disease<br />Cerebrovascular disease<br />OTHERS<br />Gastrointestinal<br />Genitourinary<br />Dermatologic<br />Infections<br />Cataracts<br />Glaucoma<br />Periodontal disease<br />
  42. 42. MECHANISM OF COMPLICATIONS<br />http://img.medscape.com/fullsize/migrated/editorial/clinupdates/2001/612/delprato_02.gif<br />
  43. 43. Advanced glycosylated end-products<br />Increased metabolism by sorbitol pathway<br /><ul><li>Alters redox potential
  44. 44. Increases cellular osmolality
  45. 45. Generated reactive oxygen free radicals</li></ul>Diacylglycerol activating protein kinase C<br />Increases flux through hexoseamine pathway.<br />PROPOSED THEORIES<br />
  46. 46. OPHTHALMIC COMPLICATIONS<br />http://images.emedicinehealth.com/images/healthwise/medical/hw/h9991431_001.jpg<br />
  47. 47. TREATMENT OF OPHTHALMIC COMPLICATIONS<br />Prevention<br />Prophylactic photocoagulation<br />Laser photocoagulation<br />Panretinal<br />focal<br />
  48. 48. RENAL COMPLICATIONS OF DM<br />Causes ESRD<br />http://3.bp.blogspot.com/-fMj_wJT6nfo/TaiM81DjrJI/AAAAAAAAAlI/xvtxy9ZHtRI/s1600/clip_image006.jpg<br />
  49. 49. Necrotisingpapillitis<br />http://missinglink.ucsf.edu/lm/IDS_106_DM_Complications/ASSETS/DMrenalNPgross.jpg<br />
  50. 50. TREATMENT OF RENAL COMPLICATIONS<br />Maintain blood glucose level<br />Maintain BP to < 130/80 mmHg<br />Use ACE-I & ARBs<br />CCBs, B-blockers, Diuretics<br />Protein restriction 0.8 g/kg/day in microalbunemia & <0.8 g/kg/day in macroalbunemia<br />Renal transplantation <br />
  51. 51. NEUROPATHY<br />http://pmj.bmj.com/content/82/964/95/F1.large.jpg<br />
  52. 52. TREATMENT OF NEUROPATHY<br />Improve glycemic control<br />Reduce chances of hypertension & hypertriglyceridemia<br />Avoid smoking, alcohol<br />Supplement vitamins<br />Daily care of foot wear<br />For chronic painful neuropathy – use antidepressants, anticonvulsant<br />
  53. 53. GI/GU COMPLICATIONS<br />Delayed gastric emptying<br />Altered small & large bowel motility<br />Nocturnal diarrhoea<br />Oesophageal dysfunction<br />Erectile dysfunction<br />Reduced sexual desire<br />Dysparenuria<br />Reduced vaginal lubrications<br />Diabetic cystopathy<br />
  54. 54. TREATMENT OF GI/GU COMPLICATIONS<br />Small frequent meals<br />Metoclopromide<br />Domperidone<br />Erythromycin<br />Interacts eithmotilin receptors<br />Loperamide<br />Octreotide<br />Diabetic cystopathy – self cathaterisation<br />Sildenafil (Viagra) for erectile dysfunction<br />
  55. 55. CARDIOVASCULAR COMPLICATIONS<br />Absence of chest pain (“Silent ischemia”) is common<br />One of the risk factors for atherosclerosis<br /> TREATMENT<br /><ul><li>Same as per the cardiac complication</li></li></ul><li>http://wirelesshealth.files.wordpress.com/2010/12/pic2001.jpg<br />
  56. 56. LOWER EXTREMITY COMPLICATIONS<br />http://missinglink.ucsf.edu/lm/IDS_106_DM_Complications/ASSETS/Ischemicfoot.jpg<br />
  57. 57. http://www.podiatrytoday.com/files/imagecache/normal/PT07Diabetes1.png<br />
  58. 58. http://www.onkocet.onkocet.eu/userfiles/image/plason_sds.jpg<br />
  59. 59. DERMATOLOGIC COMPLICATIONS<br /> NECROTISING LIPOIDICA DIABETICORUM<br />NECROBIOSIS DIABETICORUM: Atrophy of skin<br />http://accessmedicine.net/loadBinary.aspx?name=hurs13&filename=hurs13_c014f035t.jpg<br />http://accessmedicine.net/loadBinary.aspx?name=harr&filename=harr_c929f007t.jpg<br />
  60. 60. DIAGNOSIS<br />
  61. 61. SCREENING TESTS<br />Widespread use of FPG for screening is recommended because:<br />Large number of people who meet the criteria are unaware of their problem & are asymptomatic<br />Epidemiological studies show that type 2 DM may be present for a decade before the diagnosis<br />As many as 50 % of individuals with DM have one or more of the complications<br />Treatment of DM has favorably altered the natural history of the disease<br />
  62. 62. Individuals >45 years of age are to be screened every 3 years<br />Individuals who are overweight (BMI > 25) and have an additional risk factor for the disease should also be screened<br />
  63. 63. LONG TERM TREATMENT<br />
  64. 64. BEFORE GIVING MEDICATIONS<br />Diabetic education<br />Nutrition (Medical Nutrition Therapy, MNT)<br />Exercise <br />
  65. 65. PATIENT EDUCATION<br />Self-monitoring of blood glucose<br />Urine ketone monitoring<br />Self insulin administration<br />Foot & skin care<br />Management of hypoglycemia<br />
  66. 66. MEDICAL NUTRITION THERAPY<br />FATS<br />20 – 35% of total calories<br />Saturated fats < 7% of total calories<br />< 200 mg/day of dietary cholesterol<br />Two or more servings of fish/week<br />Minimal trans fats consumption<br />CARBOHYDRATES<br />45 - 65% of total calorie intake<br />Type & amount of carbohydrate is important<br />Sucrose containing food must be consumed with adjustments in insulin<br />PROTEINS<br />10 – 35% of total calorie intake<br />OTHER COMPONENTS<br />Fibre containing food may reduce postprandial glucose excrusions<br />Nonnutrient sweeteners <br />
  67. 67. EXERCISE<br />Around 150 mins/week<br />
  68. 68. ASSESSMENT OF LONG TERM GLYCEMIC CONTROL<br />GLYCATED HAEMOGLOBIN (HbA1C)<br />Non-enzymatic glycation of hemoglobin<br />Keep less than 7%<br />That is around < 170 mg/dl<br />Status of around last 3 months<br />FRUCTOSEAMINE ASSAY<br />For prior 2 weeks<br />Other method is : 1,5 anhydroglucitol assay<br />
  69. 69. TREATMENT OF DM<br />Type I DM<br />Give insulin primarily<br />Type II DM<br />Give oral hypoglycemic drugs, primarily<br />
  70. 70. TREATMENT OF TYPE I DM<br />
  71. 71. http://img.medscape.com/fullsize/migrated/501/976/smj501976.fig3.gif<br />
  72. 72. http://dtc.ucsf.edu/images/graphs/graph_sliding_multiple.gif<br />
  73. 73. http://tmedweb.tulane.edu/pharmwiki/lib/exe/fetch.php/regimens1a.png?w=600<br />
  74. 74. http://besthealth.bmj.com/x/images/bh/en-gb/diabetes-injections_default.jpg<br />
  75. 75. Other agent that can improve glucose control are:<br />Pramlintide<br />Insulin pumps<br />
  76. 76. http://www.emftesting.net/wp-content/uploads/2010/10/Insulin-Pump.jpg<br />
  77. 77. http://blood-glucose-monitor.org/wp-content/uploads/2011/02/1298891488-58.jpg<br />
  78. 78. http://t0.gstatic.com/images?q=tbn:ANd9GcRSizyl65SBOesFNMsSM1H9OtzwfCPa6WwLMfgzNHawNoTB8Ym3&t=1<br />
  79. 79. TREATMENT OF TYPE II DM<br />
  80. 80.
  81. 81. http://www.pharmainfo.net/files/images/stories/article_images/Major%20target%20organs%20and%20actions.jpg<br />
  82. 82. TIKAL KANSARA<br />INTERN<br />CIVIL HOSPITAL<br />AHMEDABAD<br />

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