DEFINITION CLASSIFICATION AND ETIOLOGY PATIENT PROFILE METABOLIC SYNDROME CLINICAL FEATURES DIAGNOSIS AND INVESTIGATIONS DAWN AND SOMOGYI PHENOMENON MANAGEMENT COMPLICATIONS AND METABOLIC MEMORY

1. Topic :- Update on DIABETES MELLITUS (2020)
Dr Rahul JainDr Sharda Jain
for Gynaecologist & Surgery Specialist

2. Over 400 ppts are available on
slideshare.net ***for use of public/Doctors
www.slideshare.net / Lifecarecentre

3. LEARNING POINTS-
• DEFINITION
• CLASSIFICATION AND ETIOLOGY
• PATIENT PROFILE
• METABOLIC SYNDROME
• CLINICAL FEATURES
• DIAGNOSIS AND INVESTIGATIONS
• DAWN AND SOMOGYI PHENOMENON
• MANAGEMENT
• COMPLICATIONS AND METABOLIC MEMORY

4. DEFINITION-
• DIABETES MELLITUS IS A METABOLIC
SYNDROME CHARACTERIZED BY
HYPERGLYCEMIA DUE TO ABSOLUTE/RELATIVE
INSULIN DEFICIENCY OR BOTH.
• NORMAL PHYSIOLOGY
• REFERENCE

7. CLASSIFICATION-
• TYPE 1 DIABETES MELLITUS
• TYPE 2 DIABETES MELLITUS
• GDM
• OTHERS-
1) MATURITY ONSET DIABETES OF YOUNG
2) ENDOCRINOPATHIES
3) INFECTIONS-VIRAL
4) DRUGS-STERIODS,DIAZOXIDE,PENTAMIDINE
5) LATENT AUTOIMMUNE DIABETES IN ADULTS(LADA)

8. PATHOGENESIS-
• TYPE 1 DM-AUTOIMMUNE DESTRUCTION OF
BETA CELLS
• GDM-PRESENCE OF HPL AND INSULINASE
• TYPE 2 DM-INSULIN RESISTANCE
Adipose cell
big
Adipose
cell

9. PATIENT PROFILE-
• TYPE 1 DM-young
child,thin,undernourished,presents with DM
symptoms,family h/o+
• Type 2 DM-middle aged to
elderly,obese,metabolic syndrome patient
with DM Symptoms,fat distribution,family
history +/-
• Gdm-pregnant patient usually in 6-7 months
of pregnancy

10. METABOLIC SYNDROME-
• 3/5 SHOULD FULFILL
TRIGLYCERIDES>150MG/DL
HDL(MALES<50MG/DL)
(FEMALES<40MG/DL)
FASTING GLUCOSE>=100MG/DL
BP>130/85MMHG
ABDOMINAL GIRTH(MALE->=102,94CM)
(FEMALE->=88,80CM)

11. CLINICAL FEATURES-

12. DIAGNOSIS-
• FASTING PLASMA GLUCOSE≥126MG/DL
• POST PRANDIAL GLUCOSE≥200MG/DL
• HbA1C≥6.5%

13. INVESTIGATIONS-
• ROUTINE INVESTIGATIONS TO LOOK FOR ANY
SIGN OF INFECTIONS
• CBC,FASTING LIPID PROFILE,LFT,KFT,SERUM
ELECTROLYTES,U/R
• FUNDOSCOPY(GUIDELINES-5YR AFTER DX
AND IMMEDIATELY AFTER DX)
• ECG AND 2D ECHO

15. DISEASES-
• GH excess-Acromegaly,Gigantism
• Glucocorticoids excess-iatrogenic,cushing’s
syndrome
• Thyroid hormone excess-hyperthyroidism
• Glucagon excess-glucagonoma
• Catecholamine excess-phaechromocytoma

16. DAWN AND SOMOGYI PHENOMENON-
• DAWN
• FASTING GLUCOSE MORE
• NIGHT INSULIN
INADEQUATE
• MEASURE 12 AND 3 AM
GLUCOSE LEVELS
• RX-INCREASE INSULIN
DOSE
• SOMOGYI
• FASTING GLUCOSE MORE
• EXCESS NIGHT INSULIN
CAUSING MIDNIGHT
HYPOGLYCEMIA
TRIGGERING EXCESS
COUNTER REGULATORY
HORMONE SECRETION
• RX-DECREASE INSULIN IN
NIGHT

17. MANAGEMENT-
• TARGETS-
1) HbA1c Target-≤7.0%
2) Pre prandial glucose<130mg/dl
3) Post prandial glucose<180mg/dl
4) BP<140/80mmhg

18. LIFESTYLE CHANGES-
• DIABETIC DIET-SHORT,FREQUENT,LOW GLYCEMIC
INDEX FOODS
• TOTAL CALORIE CONTENT OF FOOD(36KCAL/KG-
MALES,34KCAL/KG-FEMALES)
• DISTRIBUTION-C:F:P-50:30:20%
• FIBER CONTENT IN DIET
• CUT DOWN ALCOHOL CONSUMPTION AND
SMOKING
• EXERCISE AND STRESS FREE LIFE
• MEDICATIONS

19. CONCEPT OF METABOLIC
MEMORY?
(DCCT,UK PROSPECTIVE DIABETES STUDY)

20. MEDICATIONS AVAILABLE-
• Biguanides-metformin(insulin sensitiser)
• Sulfonylureas-glimepride,glyburide
• Thiazolinedinediones-PPAR-gamma agonist-
pioglitazone,rosiglitazone
• SGLT-2 inhibhitors-canagliflozin,empagliflozin
• GLP-1 agonist injectables-
exenatide,liraglutide,semaglutide
• DPP4 inhibitors-linagliptin,saxagliptin,sitagliptin.
• Alpha glucosidase inhibhitors-acarbose

21. Concept of incretins-

22. INSULIN TYPES-
• BASAL INSULINS-
NPH,Glargine,Detemir,degludec
• Rapidly acting insulins-lispro,aspart,glulisine
• Short acting-regular insulin

23. S/E AND C/I-
• WEIGHT GAIN-SULFONYLUREAS,INSULIN
• HYPOGLYCEMIA-SULFONYLUREAS,INSULIN
• PANCREATITIS-GLP-1 ANALOUGES
• HEART FAILURE-THAIZOLINEDINEDIONES
• CKD-METFORMIN NOT TO BE GIVEN

24. BRAND NAMES-
• Metformin-OKAMET,GLYCOMET 500MG,1GM
• Glimepride-GLIMP M1(1MG),GLIMP M2(2MG)
• Exenatide-EXAPRIDE 250MCG/2ML SC
INJ(USUAL DOSE-5MCG BD)
• Saxagliptin-KOMBIGLYZE –M(5MG)
• Tenegliptin-AFOGLIP-M(20MG)
• Pioglitazone-PIOGLIT 15MG

25. • Sweating is most
reliable symptom
of hypoglycemia

26. PREFERABLE DRUGS-
• PREDIABETIC,FIRST LINE-METFORMIN
• TIA,STROKE PATIENTS-PIOGLITAZONE
• H/O HYPOGLYCEMIA-GLP-1 AG,DPP4i
• HEART FAILURE AND CKD-SGLT-2 INHIBITORS

27. TREATMENT GUIDELINES-
• HbA1C>10.0%-INSULIN THERAPY
• HbA1C=9-10%-DUAL THERAPY
• FIRST DRUG TO BE ALWAYS STARTED
METFORMIN UNLESS C/I
• ADD INCRETIN OR SU OR SGLT-2 INH. AFTER
EVERY 3 MONTHS IF TARGETS NOT ACHIEVED.
• INCRETINS ARE COSTLY BUT PREFERABLE
• TYPE 1 DM,PREGNANCY-INSULIN ONLY

28. NEW ADVANCES-
• INSULIN PUMPS
• FRUCTOSAMINE ASSAY
• CONTINOUS BLOOD GLUCOSE
MONITORING(ABOTT)

29. CASE STUDIES-
• A 45YR OLD MALE,K/C/O HTN SINCE 10 YRS
WELL CONTROLLED ON TELMA-H OD AND
NOW COMES WITH ELEVATED HbA1C OF
8%,FBG-110 AND PPBG-190MG/DL DETECTED
ON ROUTINE INVESTIGATIONS,WHAT
TREATMENT PATIENT SHOULD BE STARTED
ON?

30. CASE 2-
• A 68YR OLD FEMALE K/C/O HTN,T2DM SINCE
10 YRS WITH H/O ISCHEMIC STROKE
INVOLVING RT SIDED BODY 5 YRS BACK,ON
METFORMIN 500MG BD,LOSART-H
BD,ECOSPRIN,ATORVASTATIN,MULTIVITAMINS
AND NOW COMES WITH HbA1C OF
7.8%,IDEAL TREATMENT?

31. CASE 3-
• DR RAMESH SURGEON BY PROFESSION 65 YRS
OLD MALE K/C/O T2DM SINCE 3 YRS,ON
METFORMIN 1000MG BD AND NOW
DETECTED TO HAVE HIGH HbA1C WHICH
ANTIDIABETIC DRUG CAN BE IDEALLY ADDED
IN HIS REGIME?

32. COMPLICATIONS OF DIABETES
MELLITUS-

33. ACUTE COMPLICATION-
• DIABETIC KETOACIDOSIS
1) BLOOD SUGARS>250MG/DL
2) URINARY KETONES++
3) BLOOD pH- <7.35
4) ALWAYS LOOK FOR PRECIPITATING FACTORS
AND WATCH FOR HYPOKALEMIA
• HYPEROSMOLAR HYPERGLYCEMIC STATE
• LACTIC ACIDOSIS
• HYPOGLYCEMIA

34. COMPLICATIONS MECHANISM-
• Pericyte necrosis and neoangiogenesis(VEFG
AND TGF-beta) which causes production of
leaky and incompetent blood vessels.
• AGE’s formation due to high intracellular
glucose leads to crosslinking extracellular
matrix proteins which causes basement
membrane thickening,LDL trapping in
intima,endothelial dysfunction.

36. CHRONIC COMPLICATIONS-
• MACROVASCULAR COMPLICATIONS-
ATHEROSCLEROSIS,MI,GANGRENE,CVA
• MICROVASCULAR COMPLICATIONS
1) DIABETIC NEPHROPATHY
2) DIABETIC RETINOPATHY,GLAUCOMA,CATARACT
3) DIABETIC NEUROPATHY
• INFECTIONS
• GASTROPARESIS
• CHEIROARTHROPATHY

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