Slide 3 Etiologic Classification of Diabetes Mellitus Diabetes mellitus is best described as a group of metabolic diseases character-ized by hyperglycemia. The hyperglycemia may be the result of defects in insulin secretion or insulin sensitivity, or both. Two major forms of diabetes are recognized in the most recent classification scheme, which was developed by The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, an international group, and has been adopted by both the American Diabetes Association and the World Health Organization. Type 1 diabetes includes almost all cases that are marked by destruction of the pancreatic islet -cells. Type 2 diabetes includes those cases that result from insulin resistance accompanied by a defect in insulin secretion. Other specific forms of diabetes, which affect far fewer patients than the two major forms, include genetic defects of -cell function, genetic defects in insulin sensitivity, diseases of the exocrine pancreas, endocrinopathies, drug- or chemical-induced infections, uncommon immune-mediated conditions, and other genetic conditions. Gestational diabetes mellitus is a fourth type in this new classification system. The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus . Diabetes Care . 1997;20:1183-1197.
Slide 8 Diagnosed and Undiagnosed Diabetes in the US : Estimated Cases Among Adults, 1997 Using the data collected in the Third National Health and Nutrition Examination Survey (NHANES III), 1988-1994, and applying the new diagnostic criteria for diabetes (see Slides 4 and 5), estimates for the prevalence of diabetes (diagnosed and undiagnosed) were developed for the 1997 adult US population. It was estimated that 10.2 million adults (aged 20 years) had diagnosed diabetes (fasting plasma glucose [FPG] 126 mg/dL) and 5.4 million had undiagnosed diabetes (FPG 110 mg/dL and <126 mg/dL). Thus, in the US in 1997, approximately 35% of adults with diabetes had undiagnosed disease. Harris M, Flegal K, Cowie C, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. Diabetes Care . 1998;21:518-524.
Slide 4 Glucose Tolerance Categories Either the fasting plasma glucose (FPG) test or the 2-hour plasma glucose (PG) determination during the oral glucose tolerance test (OGTT) may be used to determine glucose tolerance status. According to the most recent diagnostic criteria established by The Expert Committee on the Diagnosis and Class-ification of Diabetes Mellitus, an FPG value 126 mg/dL ( 7.0 mmol/L) or a 2-hour plasma glucose value 200 mg/dL ( 11.1 mmol/L) are the new cutoff points for the diagnosis of diabetes. The cutoff points for the intermediate stage of hyperglycemia denoted by the terms impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) have been adjusted to conform to the new diagnostic criteria for diabetes mellitus. IFG is now defined by FPG 110 mg/dL ( 6.1 mmol/L) and <126 mg/dL (<7.0 mmol/L), and IGT is defined by 2-hour PG measurements 140 mg/dL ( 7.8 mmol/L) and <200 mg/dL (<11.1 mmol/L). The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care . 1997;20:1183-1197.
CLINICAL MANAGEMENT OF DIABETES DURING PREGNANCY Antenatal, Intrapartum and Postpartum Perspectives Chukwuma I. Onyeije, M.D. Atlanta Perinatal Associates
Classification of Diabetes Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183-1197. Genetic defects in b-cell function, Pancreatic disease, Endocrinopathies, Drug- or chemical- induced, and other rare forms Other types Insulin resistance with b-cell dysfunction Gestational Insulin resistance and relative insulin deficiency Type 2 b-cell destruction with lack of insulin Type 1
Intensive Inpatient Management: The APA Hybrid Protocol
For poorly controlled diabetic patients admitted for rapid control.
Empiric insulin with the patient’s current standing dose:
Targets adequate glycemic control
Fasting values: Less than 100 mg/dl
2 hour postparandial values: Less than 120 mg/dl
Avoidance of hypoglycemia, ketonuria, and hyperglycemia
Intensive Inpatient Management: The APA Hybrid Protocol
Begin 2200 to 2400 calorie ADA diet.
Obtain fingerstick every 2 hours for 12-24 hours
Administer HUMALOG INSULIN for sliding scale
Retake blood sugar at 2 hours after EACH sliding dose noted below and repeat sliding scale dose of insulin based on FSG.
Adjust Insulin after 24 hours
Intensive Inpatient Management: The APA Hybrid Protocol 2 hours 14 Units 220-260 2 hours 16 Units >260 2 hours 12 Units 200-220 2 hours 10 Units 180-200 2 hours 6 Units 161-180 2 hours 4 Units 140-1600 4-6 hours Hold Humalog insulin < 140 Recheck Blood sugar Administer the following dosage of humalog insulin Blood sugar value
Patient CH – Before Hybrid Approach Patient CH – After Hybrid Approach
Allows the glucose transporter (GLUT4) to transport glucose into the cell.
1 2 3
Diagnosed and Undiagnosed Diabetes in the US: Estimated Cases Among Adults, 1997 Data from Harris, et al. Diabetes Care. 1998;21:518-524. 0 2 4 6 8 10 12 Undiagnosed Diagnosed 10.2 5.4 Millions of Cases
Glucose Tolerance Categories: NONPREGNANT Patients Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183-1197. FPG 126 mg/dL 110 mg/dL Impaired Fasting Glucose Normal 2-Hour PG on OGTT 200 mg/dL 140 mg/dL Diabetes Mellitus Impaired Glucose Tolerance Normal Diabetes Mellitus