Dr. Escher


Published on

  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Dr. Escher

  2. 2. DIABETES MELLITUS <ul><li>Focus: diabetes in the Medicare population </li></ul>
  3. 3. DIABETES MELLITUS <ul><li>Definition: a metabolic disorder in which </li></ul><ul><li>there is deficiency of insulin production or </li></ul><ul><li>resistance of organs to the effect of insulin </li></ul>
  4. 4. DIABETES MELLITUS <ul><li>Diabetes is a disorder of metabolism--the way our bodies use digested food for growth and energy. </li></ul><ul><li>Most of the food we eat is broken down into glucose, the form of sugar in the blood. </li></ul><ul><li>Glucose is the main source of fuel for the body. </li></ul><ul><li><http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what> </li></ul>
  5. 5. DIABETES MELLITUS <ul><li>After digestion, glucose passes into the bloodstream, where it is used by cells for growth and energy. </li></ul><ul><li>For glucose to get into cells, insulin must be present. </li></ul><ul><li>Insulin is a hormone produced by the pancreas, a large gland behind the stomach. </li></ul><ul><li><http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what> </li></ul>
  6. 6. DIABETES MELLITUS <ul><li>NORMAL: When non-diabetic people eat, the pancreas automatically produces the right amount of insulin to move glucose from blood into our cells. </li></ul><ul><li><http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what> </li></ul>
  7. 7. DIABETES MELLITUS <ul><li>DIABETES: In people with diabetes, when they eat, the pancreas either produces little or no insulin, or the cells do not respond appropriately to the insulin that is produced (or both) => glucose builds up in the blood, overflows into the urine, and passes out of the body in urine => body loses its main source of fuel even though blood contains large amounts of glucose. </li></ul><ul><li><http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what> </li></ul>
  8. 8. DIABETES MELLITUS (DM) <ul><li>TYPES OF DIABETES </li></ul><ul><ul><ul><ul><li>Type I </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Type II </li></ul></ul></ul></ul><ul><ul><ul><ul><li>MODY (Maturity Onset Diabetes of Youth </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Gestational </li></ul></ul></ul></ul>
  9. 9. DM TYPE I <ul><li>Auto-immune disease </li></ul><ul><li>Constitutes 5-10% of DM diagnosed in the USA </li></ul><ul><li>Mostly appears in children and young adults </li></ul><ul><li>Develops as a result of auto-immune destruction of beta-cells in the pancreas </li></ul><ul><li>Presents with polyuria, thirst, weight loss, marked fatigue </li></ul><ul><li>Can be complicated by coma with ketoacidosis </li></ul><ul><ul><ul><ul><ul><li><http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what> </li></ul></ul></ul></ul></ul>
  10. 10. DM TYPE II <ul><li>Most common form of diabetes </li></ul><ul><li>Involves about 90-95% of people with DM </li></ul><ul><li>Associated with: </li></ul><ul><ul><li>older age </li></ul></ul><ul><ul><li>obesity </li></ul></ul><ul><ul><li>family history of DM </li></ul></ul><ul><ul><li>prior history of gestational diabetes </li></ul></ul><ul><ul><li>physical inactivity </li></ul></ul><ul><ul><li>ethnicity </li></ul></ul><ul><ul><ul><ul><ul><li><http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what> </li></ul></ul></ul></ul></ul>
  11. 11. DM TYPE II <ul><li>Patient with type II DM usually makes enough insulin but the body cannot use it effectively => insulin resistance </li></ul><ul><li>Gradually insulin production decreases over the following years </li></ul><ul><li>Symptoms are similar to type I but develop more gradually </li></ul><ul><ul><ul><ul><ul><li><http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what> </li></ul></ul></ul></ul></ul>
  12. 12. DM TYPE II <ul><li>Symptoms of type II DM include: </li></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Frequent urination/polyuria </li></ul></ul><ul><ul><li>Thirst </li></ul></ul><ul><ul><li>Unusual weight loss </li></ul></ul><ul><ul><li>Blurred vision </li></ul></ul><ul><ul><li>Frequent infections </li></ul></ul><ul><ul><li>Slow healing of wounds or sores </li></ul></ul><ul><ul><li>Sometimes no specific symptoms </li></ul></ul><ul><ul><ul><li><http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what> </li></ul></ul></ul>
  13. 13. GESTATIONAL DIABETES <ul><li>Develops only during pregnancy </li></ul><ul><li>More common in: </li></ul><ul><ul><li>African Americans </li></ul></ul><ul><ul><li>American Indians </li></ul></ul><ul><ul><li>Hispanic Americans </li></ul></ul><ul><ul><li>women with a family history of diabetes </li></ul></ul><ul><li>Women with a history of gestational diabetes have a 20-50% chance of getting type II DM within 5-10 years <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what> </li></ul>
  14. 14. Diabetes Mellitus: Diagnosis <ul><li>Fasting plasma glucose = preferred test : Positive test is glycemia of 126mg/dL or higher after fasting at least 8 hours </li></ul><ul><li>Random plasma glucose of 200mg/dL or higher along with symptoms of diabetes </li></ul><ul><li>Oral glucose tolerance test (OGTT) plasma glucose of 200mg/dL or higher done 2 hours after ingestion of 75 grams of glucose in water </li></ul><ul><li><http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what> </li></ul><ul><li>MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004. </li></ul>
  15. 15. Diabetes Mellitus <ul><li>Hemoglobin A1c measurement is not recommended currently for diagnosis of diabetes. </li></ul><ul><li>HbA1c is used as a marker to monitor glycemia control in patients over time </li></ul><ul><li>MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004. </li></ul>
  16. 16. Pre-Diabetes <ul><li>Pre-diabetes refers to a state between “normal” and “diabetes” = fasting plasma glucose 100-125mg/dL (higher than normal but not high enough for diagnosis of diabetes) Affects about 41 million people in USA (previously referred to as either impaired fasting glucose or impaired glucose tolerance) </li></ul><ul><li>http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#types </li></ul><ul><li>MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004. </li></ul>
  17. 17. Type II Diabetes <ul><li>Diagnostic testing - when to do it: </li></ul><ul><li>People  45 years old => if normal then every 3 years </li></ul><ul><li>MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004. </li></ul>
  18. 18. Type II Diabetes: diagnostic testing <ul><li>Younger than 45 yo or more often than every 3 years if: </li></ul><ul><li>overweight </li></ul><ul><li>first degree relative with diabetes </li></ul><ul><li>member of high risk ethnic group (Afro-American, Hispanic American, Native American, Asian American, Pacific Islander) </li></ul><ul><li>delivered a baby  9 lbs. </li></ul><ul><li>gestational diabetes </li></ul><ul><li>hypertensive (BP  140/90mmHg) </li></ul><ul><li>High Density Lipoprotein cholesterol 35mg/dl or less </li></ul><ul><li>TriGlyceride level 250mg/dl or more </li></ul><ul><li>pre-diabetes </li></ul><ul><li>MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004. </li></ul>
  19. 19. DM type II: Management <ul><li>Basics: </li></ul><ul><li>healthy eating </li></ul><ul><li>physical activity </li></ul><ul><li>blood glucose testing </li></ul><ul><li>Pharmaceuticals: </li></ul><ul><li>oral medication(s) </li></ul><ul><li>insulin(s) </li></ul><ul><li>both oral medicines and insulin </li></ul>
  20. 20. DM: insulin variations <ul><li>Daily insulin requirements are influenced by: </li></ul><ul><li>diet </li></ul><ul><li>exercise </li></ul><ul><li>stress </li></ul>
  21. 21. Diabetes Management: Stress <ul><li>Stress influences response to insulin </li></ul><ul><li>Stress => increased cortisol </li></ul><ul><li>increased catecholamines </li></ul><ul><li>increased growth hormone </li></ul><ul><li>=> these hormones all lead to increased insulin resistance (thus, hyperglycemia) </li></ul>
  22. 22. Control of Diabetes <ul><li>Control of Diabetes includes: </li></ul><ul><li>glycemia control (FBS < 126mg/dL; HbA1c <7%) </li></ul><ul><li>weight management </li></ul><ul><li>blood pressure control (BP < 130/80mmHg) </li></ul><ul><li>lipid management </li></ul><ul><li>reduction in the hypercoagulable state (aspirin or clopidogrel) </li></ul>
  23. 23. DM type II: Management <ul><li>Most people with newly discovered type II DM are overweight </li></ul><ul><li>Basics are diet and exercise: </li></ul><ul><li>nutrition </li></ul><ul><li>life style modification </li></ul><ul><li>increased physical activity </li></ul><ul><li>Goal = Hemoglobin A1c < 7% </li></ul><ul><li>If this goal in not reached and maintained => pharmacotherapy (medications) </li></ul>
  24. 24. Insulins <ul><li>Type hours to onset time to peak time effective </li></ul><ul><li>Fast acting: </li></ul><ul><li>Lispro <0.25 (15min) 0.5-1.5 3-4 (max 4-6) </li></ul><ul><li>Aspart 0.17-0.33 0.67-0.83 1-3 (max 3-5) </li></ul><ul><li>Long acting </li></ul><ul><li>Glargine 2 none 24 </li></ul><ul><li>Ultralente 6-10 10-16 18-20 (max 20-24) </li></ul><ul><li>Short acting </li></ul><ul><li>regular 0.5-1.0 2-3 3-6 (max 6-8) </li></ul><ul><li>Intermediate acting </li></ul><ul><li>NPH 2-4 6-10 10-16 (max 14-18) </li></ul><ul><li>Lente 3-4 6-12 12-18 (max 16-20) </li></ul><ul><li>MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004. </li></ul>
  25. 25. Insulin <ul><li>Insulin dependency regimens - examples: </li></ul><ul><li>1. insulin glargine q24h and pre-meal insulin </li></ul><ul><li>2. NPH and regular before breakfast and supper </li></ul><ul><li>3. Rapid or short acting insulin before meals & intermediate acting insulin (NPH or Lente) at bedtime </li></ul><ul><li>4. Insulin Glargine at bedtime and rapid or short acting insulin before meals </li></ul><ul><li>Insulin regimens depend on individual patient requirements </li></ul>
  26. 26. Medications for DM type II <ul><li>Sulfonylureas & Meglitinides : promote glucose-stimulated release of insulin from pancreas (they need enough remaining beta-cell function in the pancreas to work) (insulin secretogogues) </li></ul><ul><li>Metformin : mostly blocks gluconeogenesis in the liver; also interferes with glycogenolysis and improves insulin sensitivity of muscle </li></ul><ul><li>Thiazolidinediones : bind to nuclear receptors in tissues & activate or suppress expression of specific genes (insulin sensitizers) - risk of fluid retention & weight gain; 4-12 week latency to work; monitor liver enzymes q2mo </li></ul><ul><li>Acarbose : alpha-glucosidase inhibitor; interferes with intestinal absorption of carbohydrates; causes flatulence & bloating (discontinuation) </li></ul><ul><li>MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004. </li></ul>
  27. 27. Medications for DM type II <ul><li>Sulfonylureas: insulin secretogogues </li></ul><ul><li>glyburide </li></ul><ul><li>glipizide </li></ul><ul><li>glimeperide </li></ul><ul><li>chlorpropamide </li></ul><ul><li>Meglitinides: insulin secretogogues </li></ul><ul><li>repaglinide </li></ul><ul><li>nateglinide </li></ul><ul><li>Biguanide: decreases hepatic gluconeogenesis </li></ul><ul><li>metformin </li></ul><ul><li>Thiazolidinediones : insulin sensitizers </li></ul><ul><li>pioglitazone </li></ul><ul><li>rosiglitazone </li></ul><ul><li>Alpha-glucosidase inhibitor : decreases GI absorption of carbohydrate </li></ul><ul><li>acarbose ; </li></ul>
  28. 28. Insulin in Type II DM <ul><li>Usually indicated if HbA1c > 7% despite life style modification and 2 oral medications </li></ul><ul><li>May be postponed in borderline cases where HbA1c is < 8.5% pending addition of a 3rd oral agent; otherwise => </li></ul><ul><li>Addition of bedtime dose of basal insulin therapy (glargine) to sulfonylureas +/- metformin (not thiazolidinediones because of risk of CHF from fluid retention) </li></ul>
  29. 29. The Metabolic Syndrome <ul><li>Hypertension </li></ul><ul><li>Visceral (central) obesity </li></ul><ul><li>Hypertriglyceridemia </li></ul><ul><li>Low HDL cholesterol </li></ul><ul><li>Insulin resistance or glucose intolerance </li></ul><ul><li>Prothrombotic state (high fibrinogen or plasminogen activator inhibitor [-1] in blood) </li></ul><ul><li>Proinflammatory state (high C-reactive protein in blood) </li></ul><ul><li>http://www.americanheart.org/presenter.jhtml?identifier=4756 </li></ul>
  30. 30. Acute Complications of type II DM <ul><li>Hyperglycemic hyperosmolar state: </li></ul><ul><li>common in elderly </li></ul><ul><li>triggered by underlying disorder(s) </li></ul><ul><li>risk increased in elderly due to decreased thirst reflex </li></ul><ul><li>often complicated by delirium </li></ul>
  31. 31. Acute Complications of type II DM <ul><li>Hyperglycemic hyperosmolar state: </li></ul><ul><li>serum osmolarity > 320 mosm/L </li></ul><ul><li>plasma glucose > 600mg/dL </li></ul><ul><li>dehydration </li></ul><ul><li>no ketoacidosis </li></ul><ul><li>underlying disorder(s) </li></ul>
  32. 32. Hyperosmolar State <ul><li>Therapy: </li></ul><ul><li>rehydration with hypotonic solution </li></ul><ul><li>insulin infusion (initially) </li></ul><ul><li>watch for signs of fluid overload/CHF </li></ul><ul><li>monitor potassium </li></ul><ul><li>treat underlying cause (eg UTI, cellulitis) </li></ul>
  33. 33. Hypoglycemia <ul><li>Hypoglycemia = plasma glycemia < 50mg/dL with or without symptoms </li></ul><ul><li>More common in type I DM and patients with significant renal or liver disease </li></ul><ul><li>Another reason for glucose monitoring </li></ul><ul><li>Treated with po sugar (e.g. fruit juice or glucose tablets) </li></ul><ul><li>or IV dextrose 50% in water or IV glucagon or both </li></ul>
  34. 34. Complications of DM <ul><li>Chronic complications of diabetes mellitus include: </li></ul><ul><li>Macrovascular </li></ul><ul><li>Microvascular </li></ul><ul><li>Neuropathic </li></ul>
  35. 35. Complications of DM <ul><li>Macrovascular </li></ul><ul><li>atherosclerosis/cardiovascular disease </li></ul><ul><li>peripheral vascular disease </li></ul>
  36. 36. Complications of DM <ul><li>Microvascular diabetic retinopathy : due to ischemia of retna; provokes neovascularization with vessels more fragile => leaking => scarring & fibrosis </li></ul><ul><li>diabetic nephropathy : common cause of ESRD; </li></ul><ul><li>prevention via control of blood pressure and glycemia; earliest signs urine albumin 30mg/day or 20  g/min; appears to benefit from ACE-I’s and ARB’s too </li></ul>
  37. 37. Complications of DM <ul><li>Diabetic Neuropathy </li></ul><ul><li>peripheral sensory neuropathy </li></ul><ul><li>cardiovascular autonomic neuropathy </li></ul><ul><li>gastrointestinal autonomic neuropathy </li></ul><ul><li>erectile dysfunction </li></ul><ul><li>mononeuropathy </li></ul><ul><li>diabetic foot </li></ul>
  38. 38. Complications of DM <ul><li>Peripheral sensory neuropathy </li></ul><ul><li>variable presentation </li></ul><ul><li>dysesthesia </li></ul><ul><li>tingling </li></ul><ul><li>pain </li></ul><ul><li>loss of pain sensation (risk of injury) </li></ul>
  39. 39. Complications of DM <ul><li>Cardiovascular Autonomic Neuropathy </li></ul><ul><li>orthostatic hypotension </li></ul><ul><li>lack of normal variation in heart rate with breathing, tachycardia </li></ul>
  40. 40. Complications of DM <ul><li>Gastrointestinal Autonomic Neuropathy </li></ul><ul><li>gastroparesis: nausea, bloating, vomiting (tx metoclopramide) </li></ul><ul><li>diarrhea: often nocturnal </li></ul>
  41. 41. Complications of DM <ul><li>Erectile dysfunction: </li></ul><ul><li>autonomic neuropathy </li></ul><ul><li>absent nocturnal and morning erections </li></ul><ul><li>more common than diagnosed </li></ul>
  42. 42. Complications of DM <ul><li>Mononeuropathy </li></ul><ul><li>acute local pain </li></ul><ul><li>distribution of a nerve </li></ul><ul><li>may recede if treated early with improved glucose control (glucotoxicity) </li></ul>
  43. 43. Complications of DM <ul><li>Diabetic Foot </li></ul><ul><li>sensory deficit (skin, bone, ligament) </li></ul><ul><li>fungal infection </li></ul><ul><li>wounds </li></ul><ul><li>pulses (PVD) </li></ul><ul><li>slow healing </li></ul><ul><li>ulcers </li></ul>
  44. 44. Type II DM: Goals <ul><li>Prevention of pre-diabetes </li></ul><ul><li>Prevention of change from pre-diabetes to diabetes </li></ul><ul><li>Diagnosis through screening </li></ul><ul><li>Early management/therapy </li></ul><ul><li>Prevention of complications </li></ul>
  45. 45. Type II DM: Goals <ul><li>Screening via fasting glycemia and history </li></ul><ul><li>Life-style history and modification </li></ul><ul><li>Physical activity </li></ul><ul><li>Diet </li></ul><ul><li>Treatment of glycemia, lipids, hypercoagulable state, blood pressure </li></ul><ul><li>Management of complications </li></ul>