A 30-year-old man was brought to the emergency room unconscious. He was diagnosed with diabetes based on diagnostic criteria of an A1C of 6.5% or higher, fasting plasma glucose of 126 mg/dL or higher, or 2-hour plasma glucose of 200 mg/dL or higher during an oral glucose tolerance test. The document discusses the classification, management, and treatment goals of diabetes, including lifestyle modifications, medication (oral hypoglycemics, insulin, GLP-1 agonists), and screening and treatment of complications such as hypertension, dyslipidemia, and kidney disease.

1. Pratap sagar Tiwari, MD, Internal Medcine,
Lecturer, NMCTH
UNDERSTANDING DIABETES..PART 3

2. CASE SUMMARY
• A 30 yrs old M was brought in ERD in the state of unconsciousness.
(Note: Coma is a symptom, not a diagnosis.)
Pic taken from http://censorbugbear-reports.blogspot.com/2010/03/shocking-neglect-of-comatose-patient-at.html

3. RECAP OF PREVIOUS PARTS
• Causes of patient in state of coma
• Definition of terms related to consciousness
• Causes of Coma in a Diabetic Patient
• Insulin Synthesis/ Secretion
• Regulation of Glucose hemostasis
• Response of hypoglycemia in normal & DM
• Hypoglycemia & symptoms
• DKA /HHS
• Abnormal respiration patterns

4. DIABETES MELLITUS
• Diabetes mellitus is a clinical syndrome characterised by
hyperglycaemia caused by absolute or relative deficiency of
insulin.

5. DIAGNOSTIC CRITERIA
• A1C ≥6.5%
• OR
• Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L)
OR
• 2-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT
OR
• A random plasma glucose ≥200 mg/dL (11.1 mmol/L), in patients with
classic symptoms of hyperglycemia or hyperglycemic crisis

6. PRE DIABETES
1. IFG: fasting plasma glucose (FPG) levels of 100–
125 mg/dL (5.6–6.9 mmol/L)*
2. IGT: 2-hour plasma glucose (2-h PG) in the 75-g oral
glucose tolerance test (OGTT) of 140–199 mg/dL
(7.8–11.0 mmol/L)
3. A1c: 5.7-6.4%
Note: In 1997 and 2003, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus recognized a
group of individuals whose glucose levels did not meet the criteria for DM, but were too high to be considered N.
These persons were defined as having IFG or IGT.

7. PREDIABETES
• Individuals with IFG and/or IGT have been referred to as
having pre-diabetes, indicating a relatively high risk for
future development of diabetes
• IFG and IGT are associated with obesity (especially
abdominal or visceral obesity), dyslipidemia with high
triglycerides and/or low HDL cholesterol, and
hypertension
• Note: WHO and a number of other diabetes organizations
define the cutoff for IFG at 110 mg/dL (6.1 mmol/L)

9. SCREENING FOR AND DIAGNOSIS OF GDM
• Perform a 75-g OGTT, with plasma glucose measurement fasting and at 1
and 2 h, at 24–28 weeks of gestation in women not previously diagnosed
with overt diabetes.
• The OGTT should be performed in the morning after an overnight fast of at
least 8 h.
• The diagnosis of GDM is made when any of the following plasma glucose
values are exceeded:
1. Fasting: ≥92 mg/dL (5.1 mmol/L)
2. 1 h: ≥ 180 mg/dL (10.0 mmol/L)
3. 2 h: ≥ 153 mg/dL (8.5 mmol/L)

10. CLASSIFICATION OF DIABETES
1. Type 1 diabetes (due to β-cell destruction, usually leading to absolute
insulin deficiency)
2. Type 2 diabetes (due to a progressive insulin secretory defect on the
background of insulin resistance)
3. Other specific types of diabetes due to other causes; e.g., genetic defects in
β-cell function, genetic defects in insulin action, diseases of the exocrine
pancreas (such as cystic fibrosis), and drug- or chemical-induced diabetes
(such as in the treatment of HIV/AIDS or after organ transplantation)
4. Gestational diabetes mellitus (GDM)(diabetes diagnosed during
pregnancy that is not clearly overt diabetes)

11. MANAGEMENT
• Dietary and lifestyle modification including exercise and
weight reduction if obese
• Manage hyperglycemia : OHA / Insulin therapy
• Management of complications of diabetes, including
treatment of HTN(<140/80) and dyslipidaemia.
• Patient Education / Vaccination (influenza,
pneumococcal , hepatitis b)

12. GOAL
• Attain individualized glycemic, blood pressure, and lipid goals.
General recommended goals from the ADA for these markers are
as follows:
• A1C < 7%.
• Blood pressure < 140/80 mmHg.
• LDL cholesterol < 100 mg/dL; triglycerides < 150 mg/dL;
• HDL cholesterol < 40 mg/dL for men; HDL cholesterol < 50
mg/dL for women.
• Achieve and maintain body weight goals.

13. ASPIRIN
• Consider aspirin therapy (75–162 mg/ day) as a primary
prevention strategy in those with type 1 or type 2 diabetes at
increased cardiovascular risk .
• This includes most men aged >50 years or women aged >60
years who have at least one additional major risk factor (family
history of CVD, hypertension, smoking, dyslipidemia, or
albuminuria).

14. STATIN
• Statin therapy should be added to lifestyle therapy,
regardless of baseline lipid levels, for diabetic patients:
1. with overt CVD
2. without CVD who are over the age of 40 years and
have one or more other CVD risk factors (family history
of CVD,hypertension, smoking, dyslipidemia,or
albuminuria).

15. ACE INHIBITOR
• An ACE inhibitor or ARB for the primary prevention of diabetic
kidney disease is not recommended in diabetic patients with
normal blood pressure and albumin excretion <30 mg/24 h. B
• Either ACE inhibitors or ARBs (but not both in combination) are
recommended for the treatment of the nonpregnant patient with
modestly elevated (30–299 mg/24 h) C or higher levels (.300
mg/24 h) of urinary albumin excretion. A

16. OHA
• Biguanides eg Metformin
• Thiazolidinediones eg Pioglitazone
• Sulfonylureas eg Glimepiride
• Meglitinide eg Mitiglinide, Repaglinide, Nateglinide
• Glucosidase inhibitors eg Acarbose, voglibose, miglitol
• Dipeptidyl peptidase IV inhibitors eg Sitagliptin
• SGLT2 inhibitor: eg Dapagliflogin, canagliflozin

17. DIPEPTIDYL PEPTIDASE IV INHIBITORS

18. PARENTERAL
• Insulin
• GLP-1 receptor agonists eg Exenatide, Liraglutide
• Amylin agonists eg pramlintide

19. END OF SLIDES
References:
1. Harrison's Principles of Internal Medicine, 18th Edition
2. Davidson Practice of Medicine
3. Uptodate 20.3
4. Standards of Medical Care in Diabetesd 2014. American Diabetes Association. Diabetes
Care Volume 37, Supplement 1, January 2014
5. Medscape.com
6. Mercksmanual