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Diagnosis of diabetes mellitus


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Diagnosis of diabetes mellitus

  1. 1. Prof Dr .Dilek GogasYavuz, MD Marmara University Department of Internal Medicine Section of Endocrinology and Metabolism CLASSIFICATION AND DIAGNOSIS OF DIABETES MELLITUS
  2. 2. Diabetes MellitusDiabetes Mellitus Increasing Prevalence of Diagnosed CasesIncreasing Prevalence of Diagnosed CasesPersonsWithDiagnosedPersonsWithDiagnosed Diabetes(millions)Diabetes(millions) Diabetes OverviewDiabetes Overview. October 1995 (updated 1996). NIDDK publication NIH 96. October 1995 (updated 1996). NIDDK publication NIH 96--1468.1468. Kenny SJ et al. In:Kenny SJ et al. In: Diabetes in AmericaDiabetes in America. 2nd ed. 1995:47. 2nd ed. 1995:47--67.67. YearYear 88 77 66 55 44 33 22 00 11 19581958 19631963 19681968 19791979 19841984 19891989 19941994 8,000,0008,000,000 5X increase5X increase
  3. 3. 1.0 7.9 22.4 13.1 13.4 1997 = 124 million World 66.1 1.3 14.1 32.9 22.5 17.5 2010 = 221 million 132.3 Global Estimates and Projections of Diabetes (in millions) 1997-2010 Increase (78%) (31%) (72%) (47%) (78%) (100%) (30%)
  4. 4. Türkiyede Diyabet 1.9911.991 milyonmilyon kikişşii (1998)(1998) NNüüfusfus: 64.4: 64.4 milyonmilyon kikişşii 2.217 milyon kişi (2000) 4.5514.551 milyonmilyon kikişşii (2025)(2025) WHO Diabetes Report 2000 Prevelance 6% in Turkey DIABETES IN TÜRKİYE Estimated diabetes prevalance according to WHO
  5. 5. Type 2 diabetes prevalance in TURKEY 1997-2010 7,4 13,7 3 5 7 9 11 13 15 1998 2010 Prevalanceofdiaberes(%) TURDEP I and II
  6. 6. 1-diabetes type 2 %7.2 2-impaired glucose tolerance %6.7 TURDEP-1- 19971 TURDEP-2- 2010 1-diabetes type 2 %13,7 2- impaired glucose tolerance %13,9 1.Turdep I Population-Based Study of Diabetes and Risk Characteristics inTurkey.Satman et al. Diab Care,2002. 25:1551–1556. 2.TURDEP II. Satman et al.2010. prevalence
  7. 7. Definition of Diabetes  “A group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.”  “Hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels.” ADA DiabetesCare (Suppl 1) 2007
  8. 8. Etiologic classification of diabetes mellitus 1.Type 1 diabetes (B-cell destruction usually leading to absolute insulin deficiency) a.Immune mediated b.Idiopathic 2.Type 2 diabetes (combination of resistance to insulin action and an inadequate compensatory insulin secretory response) 3.Other spesific types (diabetes secondary to recognized genetic defects, diseases of the exocrine pancreas, other endocrinopathies, or to drugs) 4. Gestational diabetes Mellitus
  9. 9. 3.Other spesific types A. Genetic defects of B-cell function MODY3,MODY2,MODY1 Mitekondrial DNA defects B.Genetic defects in insulin action type A insulin resistance leprechaunism Rabson-Mendenhall syndrome lipoatrophic diabetes C.Diseases of the exocrine pancreas pancreatitis trauma/ pancreatectomy Neoplasia, Cystic fibrosis hemochromatosis fibrocalculous pancreatopathy D. Endocrinopathies Acromegaly Cushings Syndrome Glucagonoma,pheochromocytoma Hyperthyroidism,somatostatinoma aldosteronoma E. Drug or chemical induced Vacor, pentamidine nicotinic acid,glucocorticoids thyroid hormons,diazoxide B-adrenergic agonists thiazides,dilantin,a-interferon F. Infections congenital rubella cytomegalovirus G.Uncommon forms of immune-mediated DM stiff man syndrome anti-insulin receptor antibodies H. Genetic syndromes sametimes associated with diabetes Down’s syndrome Klenifelter Syndrome Turner’s syndrome Wolframs Syndrome friedrich’s ataxia myotonic dystrophy porphyria
  10. 10. Incidence of Diabetes Mellitus 7% Type 1 ( formerly Insulin dependent diabetes mellitus) 90% Type 2 (formerly Non-insulin dependent diabetes mellitus) Gestational Diabetes 5% of all pregnancies
  11. 11.  Fasting plasma glucose > 126 mg/dl (7mmol/L)  Symptoms of diabetes + plasma glucose >200 mg/dl Symptoms:polyuria,polydipsia,unexplained weight loss  2 hour plasma glucose >200 mg/dl during OGTT  A1C ≥6.5% American diabetes association 20112 Diabetes care 2012 suppl 1 Criteria for the diagnosis of diabetes mellitus OGTT: oral glukoz tolerance test
  12. 12. Categories of Fasting plasma glucose (FPG)  < 110 mg/dl = normal fasting glucose  >110 mg/dl- <126 mg/dl =impaired fasting glucose  >126 mg/dl =provisional diagnosis of diabetes the diagnosis must be confirmed Fasting is defined as no caloric intake for at least eight hours
  13. 13. Oral glucosetolerancetest(OGTT)  2-h postload glucose <140 mg/dl= normal glucose tolerance  2-h PG > 140 mg/dl and < 200 mg/dl= impaired glucose tolerance  2-h PG > 200 mg/dl = DIABETES
  14. 14. HOW TO PERFORM ORAL GLUCOSE TOLERANCE TEST ? dissolve 75 gr glucose in a glass of drinking water (200-300 ml water) Ask patient to drink in 5 min (zero point) Check plasma glucose level at the second hour of glucose load
  15. 15. Blood glucose response after an oral glucose load in Non diabetic and Diabetic subject Hour Serumglucose(mg/dl)
  16. 16. Blood glucose and insulin response after an oral glucose load (75 g glucose) in type 2 diabetes Hour
  17. 17.  As with most diagnostic tests, a test result diagnostic of diabetes should be repeated to rule out laboratory error • unless the diagnosis is clear on clinical grounds, such as a patient with a hyperglycemic crisis or classic symptoms of hyperglycemia and a random plasma glucose ≥200 mg/dL • It is preferable that the same test be repeated for confirmation, since there will be a greater likelihood of concurrence in this case. •However, if two different tests (such as A1C and FPG) are both above the diagnostic thresholds, the diagnosis of diabetes is also confirmed
  18. 18. Prediabetes associated with the metabolic syndrome, which includes obesity (especially abdominal or visceral obesity), dyslipidemia of the high-triglyceride and/or low-HDL type, and hypertension pre-diabetes FPG 100 - 125 mg/dl =impaired fasting glucose 2-h PG in the OGTT 140 - 199 mg/dl = impaired glucose tolerance A1C 5.7–6.4% Categories of increased risk for diabetes
  19. 19. NATURAL HISTORY OF IGT After 10 years Normal Diabetes IGT IGT
  20. 20. Glucose Tolerance Categories Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2013 suppl 1. FPG 126 mg/dL 110 mg/dL 7.0 mmol/L 6.1 mmol/L Impaired Fasting Glucose Normal 2-Hour PG on OGTT 200 mg/dL 140 mg/dL 11.1mmol/L 7.8 mmol/L Diabetes Mellitus Impaired Glucose Tolerance Normal Diabetes Mellitus
  21. 21. Testing to detect type 2 diabetes and assess risk for future diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI ≥25 kg/m2) and who have one or more additional risk factors for diabetes TESTING FOR DIABETES IN ASYMPTOMATIC PATIENTS
  22. 22. Criteria for testing for diabetes in asymptomatic adult individuals Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2*) and who have one or more additional risk factors: • physical inactivity • first-degree relative with diabetes •high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian •women who delivered a baby weighing >4 kg or who were diagnosed with GDM •hypertension (blood pressure ≥140/90 mmHg or on therapy for hypertension) •HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L) •women with PCOS •A1C ≥5.7%, IGT, or IFG on previous testing •other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) •history of CVD
  23. 23. Risk Factors for Type 2 Diabetes  Age > 40  Family history of diabetes  Ethnicity  Obesity; abdominal fat distribution  GDM, or give birth infant > 4 kg  Hypertension, hyperlipidemia  Previous Impaired GlucoseTolerance
  24. 24. In those without these risk factors, testing should begin at age 45 years. If tests are normal, repeat testing at least at 3-year intervals is reasonable. To test for diabetes or to assess risk of future diabetes, the A1C, FPG, or 2-h 75-g OGTT are appropriate. TESTING FOR DIABETES IN ASYMPTOMATIC PATIENTS
  26. 26. GESTATIONAL DIABETES MELLITUS (GDM) •GDM is defined as any degree of glucose intolerance with onset or first recognition during pregnancy •GDM complicate 4-5 % of all pregnancies •Six months or more after pregnancy ends, the women should be reclassified
  27. 27. Low risk Medium risk Very high risk BMI < 25 kg/m 2 BMI25- 29.9 kg/m 2 BMI> 30kg/m 2 BMI: body mass index Screen for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria
  28. 28. DETECTION AND DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS (GDM) Screen for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria. In pregnant women not previously known to have diabetes, screen for GDM at 24–28 weeks’ gestation, using a 75-g 2-h OGTT and the diagnostic cut points Screen women with GDM for persistent diabetes at 6–12 weeks’ postpartum, using a test other than A1C. Women with a history of GDM should have lifelong screening for the development of diabetes or prediabetes at least every 3 years.
  29. 29. Perform a 75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 24–28 weeks’ gestation in women not previously diagnosed with overt diabetes. The diagnosis of GDM is made when any of the following plasma glucose values are exceeded: plasma glucose • Fasting ≥92 mg/dL • 1 h ≥180 mg/dL • 2h ≥153 mg/dL Screening for and diagnosis of GDM The OGTT should be performed in the morning after an overnight fast of at least 8 h.
  30. 30. Because some cases of GDM may represent preexisting undiagnosed type 2 diabetes, women with a history of GDM should be screened for diabetes 6–12 weeks’ postpartum, using nonpregnant OGTT criteria.  Because of their prepartum treatment for hyperglycemia, use of the A1C for diagnosis of persistent diabetes at the postpartum visit is not recommended Women with a history of GDM have a greatly increased subsequent risk for diabetes and should be followed up with subsequent screening for the development of diabetes or prediabetes Postpartum period
  31. 31. Thank you