2. DIABETES MELLITUS Diabetes Mellitus (DM) refers to a group of common metabolic disorders that share the common phenotye of hyperglycemia Depending on etiology, factors contributing to hyperglycemia includes: Reduced insulin secretion Decreased glucose utilization Increased glucose production
3. CLASSIFICATION Type I DM Type II DM Other specific types: Genetic deficiency of B- cell functions Hepatocyte nuclear transcriptioon factor 4 alfa (MODY 1) Glucokinase (MODY 2) HNF – 1alfa (MODY 3) Insulin promoter factor 1 (MODY 4) HNF 1beta (MODY 5) neuroD1 (MODY 6)
4. Genetic defects in insulin action Type A insulin resistance Leprechaunism Lipodystrophy syndromes Dieases of exocrine pancreas: pancreatitis, pancreatectomy, neoplasia, cystic fibrosis, hemochromatosis Endocrinopathies: Acromegaly, Cushing Syndrome, pheochromocytoma, hyperthyroidism Drug or chemical induced: pentamitice, nicotinic acid, glucocorticoids, thyroid hormones, phenytion, protease inhibitors, clozapine Infections: congenital rubella, CMV, Coxsachie Uncommon forms: anti-insulin receptor antibodies Other genetic conditions associated with Diabetes: Down Syndrome, Klinefelter Syndrome, Turner’s Syndrome, Friedrich’s Ataxia, Huntington’s Chorea, Porphyria Gestational Diabetes Mellitus
6. NORMAL PHYSIOLOGY OF INSULIN ACTION http://1.bp.blogspot.com/_N-RTY7s9S4A/SJwltA7yq7I/AAAAAAAAAUg/-rtv3wsulaE/s400/Insulin.jpg
7. RISK FACTORS FOR DIABETES MELLITUS Family history of diabetes (parent or sibling) Obesity (BMI > 25) Habitual physical inactivity Race/ethinicity Previously identified IFG or IGT History of GDM or delivery of baby > 4 kg Hypertension ( BP > 140/90 mmHg ) HDL cholestrol level < 35 mg/dl &/or a TG level > 250 mg/dl PCOD or Acanthosisnigricans History of vascular disease
8. PATHOGENESIS OF DM 1 http://www.discoverymedicine.com/Didier-Hober/files/2010/08/discovery_medicine_hober_no51_figure_5.jpg
14. MAIN INSULIN RESISTANCE SYNDROMES The main insulin resistance syndromes include The Metabolic Syndrome (Syndrome X) Polycystic Ovary Syndrome (PCOS)
36. SHORT ACTING INSULIN IV (0.1 U/kg) or IM (0.3 U/kg) stat Then, 0.1 U/kg/hr continuous infusion; increase to 2 to 3 times, if no response by 2 – 4 hrs If initial potassium < 3.3 mEq/L, do not administer insulin till potassium corrected to > 3.3 mEq/L
37.
38.
39.
40. CHRONIC COMPLICATIONS OF DM MICROVASCULAR Eye disease Retinopathy Macular oedema Neuropathy Sensory Motor Autonomic Nephropath
50. TREATMENT OF RENAL COMPLICATIONS Maintain blood glucose level Maintain BP to < 130/80 mmHg Use ACE-I & ARBs CCBs, B-blockers, Diuretics Protein restriction 0.8 g/kg/day in microalbunemia & <0.8 g/kg/day in macroalbunemia Renal transplantation
52. TREATMENT OF NEUROPATHY Improve glycemic control Reduce chances of hypertension & hypertriglyceridemia Avoid smoking, alcohol Supplement vitamins Daily care of foot wear For chronic painful neuropathy – use antidepressants, anticonvulsant
53. GI/GU COMPLICATIONS Delayed gastric emptying Altered small & large bowel motility Nocturnal diarrhoea Oesophageal dysfunction Erectile dysfunction Reduced sexual desire Dysparenuria Reduced vaginal lubrications Diabetic cystopathy
54. TREATMENT OF GI/GU COMPLICATIONS Small frequent meals Metoclopromide Domperidone Erythromycin Interacts eithmotilin receptors Loperamide Octreotide Diabetic cystopathy – self cathaterisation Sildenafil (Viagra) for erectile dysfunction
61. SCREENING TESTS Widespread use of FPG for screening is recommended because: Large number of people who meet the criteria are unaware of their problem & are asymptomatic Epidemiological studies show that type 2 DM may be present for a decade before the diagnosis As many as 50 % of individuals with DM have one or more of the complications Treatment of DM has favorably altered the natural history of the disease
62. Individuals >45 years of age are to be screened every 3 years Individuals who are overweight (BMI > 25) and have an additional risk factor for the disease should also be screened
65. PATIENT EDUCATION Self-monitoring of blood glucose Urine ketone monitoring Self insulin administration Foot & skin care Management of hypoglycemia
66. MEDICAL NUTRITION THERAPY FATS 20 – 35% of total calories Saturated fats < 7% of total calories < 200 mg/day of dietary cholesterol Two or more servings of fish/week Minimal trans fats consumption CARBOHYDRATES 45 - 65% of total calorie intake Type & amount of carbohydrate is important Sucrose containing food must be consumed with adjustments in insulin PROTEINS 10 – 35% of total calorie intake OTHER COMPONENTS Fibre containing food may reduce postprandial glucose excrusions Nonnutrient sweeteners
68. ASSESSMENT OF LONG TERM GLYCEMIC CONTROL GLYCATED HAEMOGLOBIN (HbA1C) Non-enzymatic glycation of hemoglobin Keep less than 7% That is around < 170 mg/dl Status of around last 3 months FRUCTOSEAMINE ASSAY For prior 2 weeks Other method is : 1,5 anhydroglucitol assay
69. TREATMENT OF DM Type I DM Give insulin primarily Type II DM Give oral hypoglycemic drugs, primarily
