Diabetes Mellitus Diabetes Mellitus Hyperglycemia characterized by - - PDF document

HIHIM 409 - Clinical Cocepts for Managers Fernando Vega, MD 1

Diabetes Mellitus Diabetes Mellitus

Fernando Vega, MD Fernando Vega, MD HIHIM 409 HIHIM 409 2011 2011

Diabetes Mellitus Diabetes Mellitus

Hyperglycemia characterized by relative or Hyperglycemia characterized by relative or absolute lack of insulin secretion absolute lack of insulin secretion Varying degrees of insulin resistance Varying degrees of insulin resistance Oft i t d ith t l i Oft i t d ith t l i

2

Often associated with symptoms: polyruia, Often associated with symptoms: polyruia, polydipsia, unexplained weight loss polydipsia, unexplained weight loss

Insulin Insulin

Enhances peripheral glucose uptake Enhances peripheral glucose uptake Inhibits breakdown of liver glycogen Inhibits breakdown of liver glycogen Enhances storage of glucose as glycogen Enhances storage of glucose as glycogen

3 3

Increases protein synthesis Increases protein synthesis Increases triglyceride storage Increases triglyceride storage

Diabetes Mellitus Diabetes Mellitus

Normal fasting glucose < 100 Normal fasting glucose < 100 Normal postprandial glucose <140 Normal postprandial glucose <140

4

Diabetes Mellitus Diabetes Mellitus

Fasting Fasting 2 hours pp 2 hours pp Normal Normal < 100 < 100 < 140 < 140

5 5

IFG IFG 100 100 -

• 125

125 IGT IGT 140 140-

• 200

200 Diabetes Diabetes > 126 > 126 > 200 > 200

Diabetes Mellitus Diabetes Mellitus

Another definition

Hemoglobin A1c equal or greater than 6.5%

6

g q g

(Adopted by the American Diabetes Association in 2010)

HIHIM 409 - Clinical Cocepts for Managers Fernando Vega, MD 2

Diabetes Mellitus Diabetes Mellitus

Classification of Diabetes Type 1 – Destruction of pancreatic beta cells leading to absolute insulin deficiency

7 7

Type 2 – Variable degrees of insulin deficiency and resistance Terminology Gestational diabetes Diabetes secondary to other conditions

Diabetes Mellitus Diabetes Mellitus

The majority diabetes seen is Type 2 The majority diabetes seen is Type 2 The majority of Type 2 diabetics have no The majority of Type 2 diabetics have no awareness of their disease at the time of awareness of their disease at the time of diagnosis diagnosis diagnosis diagnosis The majority of Type 2 diabetics The majority of Type 2 diabetics

– Are estimated to go undiagnosed or untreated Are estimated to go undiagnosed or untreated for months and years for months and years – Have more insulin than the average person Have more insulin than the average person

8

Type 1 diabetes Type 2 diabetes Type 1 diabetes Type 2 diabetes

Juvenille Juvenille (usually) (usually) Abrupt onset Abrupt onset Family history Family history Autoimmune Autoimmune Older age (usually) Older age (usually) Slow onset Slow onset Family history Family history Not autoimmune Not autoimmune

9 9

Ketones Ketones Total insulin Total insulin def def, , Islet cell AB Islet cell AB pos pos HLA DR3 DR4 HLA DR3 DR4 Insulin dependent Insulin dependent Not autoimmune Not autoimmune No ketones No ketones Partial Insulin deficiency, Partial Insulin deficiency, resistance resistance Insulin requiring Insulin requiring Diet influenced Diet influenced

Secondary Diabetes Secondary Diabetes

Steroids Steroids Thiazide Diuretics Thiazide Diuretics Drugs for HIV Drugs for HIV Pancreatectomy Pancreatectomy Acute pancreatitis Acute pancreatitis Chronic Pancreatitis Chronic Pancreatitis Haemachromatosis Haemachromatosis Cystic Fibrosis Cystic Fibrosis

10 10

Pancreatectomy Pancreatectomy Cystic Fibrosis Cystic Fibrosis Cushings Disease Cushings Disease Acromegaly Acromegaly MODY MODY DIDMOAD DIDMOAD

Diabetes Mellitus Diabetes Mellitus

Prevalence: 7% of the US population has diabetes ½ of them are undiagnosed

11 11

The prevalence is increasing

Diabetes Mellitus Diabetes Mellitus

Patient with diabetic symptoms Patient with diabetic symptoms

– Polyuria, polydipsia, weight loss, fatigue Polyuria, polydipsia, weight loss, fatigue

Typical presentations:

– Sleepiness, coma Sleepiness, coma

Patient with another illness that Patient with another illness that precipitates a diabetic crisis precipitates a diabetic crisis Patient with discovery on routine Patient with discovery on routine screening screening

12 12

HIHIM 409 - Clinical Cocepts for Managers Fernando Vega, MD 3

Diabetes Mellitus Diabetes Mellitus

Clinical Management – Acutely In office Inpatient

13 13

p Assessment of progression

Diabetes Mellitus Diabetes Mellitus

Clinical Management – Long Term Glycemic control Diet, excercise Oral hypoglycemics

14 14

yp g y Insulin Blood pressure control Lipid control Preventing, Monitoring complications

Treatments for Hyperglycemia Treatments for Hyperglycemia

Diet Diet Metformin Metformin Sulphonylureas Sulphonylureas

Regular Insulin Regular Insulin Long acting Insulin Long acting Insulin Analogue insulins Analogue insulins

15 15

Acarbose Acarbose Thiazolidinediones Thiazolidinediones Netaglinide/Repag. Netaglinide/Repag.

Mixed insulins Mixed insulins

Other treatments Other treatments

Anti Anti-

• hypertensives

hypertensives Statins/fibrates Statins/fibrates Aspirin Aspirin

16 16

ACE inhibitors ACE inhibitors ARBs ARBs

Treat to Target Treat to Target

HbA1C < 7% HbA1C < 7% BP < 135/80 BP < 135/80 Cholesterol <5 Cholesterol <5 mmol mmol/l /l

17 17

HDL HDL-

• C >1mmol/l

C >1mmol/l Triglycerides <1.5mmol/l Triglycerides <1.5mmol/l

Diabetes Mellitus Diabetes Mellitus

Clinical Course of Diabetes Immediate consequences Early consequences

18 18

y q Late consequences

HIHIM 409 - Clinical Cocepts for Managers Fernando Vega, MD 4

Diabetes Mellitus Diabetes Mellitus

Clinical Course of Diabetes - Early consequences Tendency to yeast infections

19 19

Diabetes Mellitus Diabetes Mellitus

Clinical Course of Diabetes - Immediate consequences Visual blurring Hypoglycemic episodes Weight changes

20 20

g g

Diabetes Mellitus Diabetes Mellitus

Clinical Course of Diabetes - Late consequences Microvascular Disease: Neuropathy

21 21

p y Nephropathy Retinopathy Atherosclerosis Coronary artery Peripheral Vascular Disease

Neuropathy Neuropathy

Peripheral Neurop Peripheral Neurop Femoral Amyotrophy Femoral Amyotrophy Mononeuritis Mononeuritis multiplex multiplex Autonomic Autonomic Neuropathy Neuropathy Postural hypotension Postural hypotension Diarrhoea Diarrhoea

22 22

multiplex multiplex Diarrhoea Diarrhoea Impotence Impotence Atonic bladder Atonic bladder Sweating Sweating Loss of hypo. awarenes Loss of hypo. awarenes

Nephropathy Nephropathy

Diabetic Diabetic glomerulosclerosis glomerulosclerosis Microalbuminuria Microalbuminuria <300mg/l <300mg/l Glycaemic control Glycaemic control BP control BP control CAPD CAPD Transplantation Transplantation

23 23

g Proteinuria >300mg/l Proteinuria >300mg/l Nephrotic >3g/l Nephrotic >3g/l Abnormal creatinine Abnormal creatinine Transplantation Transplantation

Retinopathy Retinopathy

Background DR Background DR Pre Pre-

• proliferative DR

proliferative DR Proliferative DR Proliferative DR Maculopathy Maculopathy Fluroscein Fluroscein angiography angiography Laser Laser Blood Pressure Blood Pressure

24 24

Maculopathy Maculopathy Blood Pressure Blood Pressure Lipids Lipids Glucose Glucose

HIHIM 409 - Clinical Cocepts for Managers Fernando Vega, MD 5

Vascular Disease in Diabetes Vascular Disease in Diabetes

Peripheral Vascular Disease Peripheral Vascular Disease Cerebrovascular Disease Cerebrovascular Disease Coronary Artery Disease Coronary Artery Disease

25 25

Coronary Artery Disease Coronary Artery Disease

Angina Angina MI MI Silent infarct Silent infarct CCF CCF ECG ECG Cardiac enzymes Cardiac enzymes Troponin I Troponin I Exercise stress test Exercise stress test

26 26

CCF CCF Exercise stress test Exercise stress test Echocardiography Echocardiography Angiography Angiography Angioplasty/CABG Angioplasty/CABG

Cerebrovascular Disease Cerebrovascular Disease

TIAs TIAs CVAs CVAs Dementia Dementia CT scan CT scan Carotid Dopplers Carotid Dopplers Treat risk factors Treat risk factors Carotid bypass Carotid bypass

27 27

Carotid bypass Carotid bypass surgery surgery

Peripheral Vascular Disease Peripheral Vascular Disease

Intermittent Intermittent Claudication Claudication Cold Legs Cold Legs Pulseless Leg Pulseless Leg Doppler Studies Doppler Studies Duplex Scanning Duplex Scanning Angiography Angiography Angioplasty Angioplasty

28 28

Pulseless Leg Pulseless Leg Foot Ulcers Foot Ulcers Gangrene Gangrene Angioplasty Angioplasty Treat risk factors Treat risk factors

Diabetic Foot Diabetic Foot

Neuropathy Neuropathy PVD PVD Charcot Arthropathy Charcot Arthropathy Ulceration Ulceration MRI MRI Angiography Angiography

29 29

Ulceration Ulceration

Diabetes Mellitus Diabetes Mellitus

Clinical Management – Anticipatory prevention Evaluation of Diabetic Complications Routine Eye exams

30 30

y Routine Foot exams Screening for microalbuminuria Screening for atherosclerosis / coronary heart disease

HIHIM 409 - Clinical Cocepts for Managers Fernando Vega, MD 6

Diabetes Mellitus Diabetes Mellitus

Clinical Management – Anticipatory prevention Reducing the risk for microvascular Disease Smoking cessation

31 31

g Aspririn Blood pressure control Dyslipidemia

Diabetes Mellitus Diabetes Mellitus

Clinical Management – Management of Complications Coronary Artery Disease

• silent MI’s require more vigilance

32 32

Kidney disease

• Prevention is the mainstay of treatment

Eye disease – diabetic retinopathy

Economic/Social facts Economic/Social facts

1:14 adults 1:14 adults 1:8 40 1:8 40-

• 75

75 1:5 >75 1:5 >75

By 2025 more people By 2025 more people worldwide will have worldwide will have diabetes than now diabetes than now live in N America live in N America

33 33

1:3 Unaware of diagnosis 1:3 Unaware of diagnosis Type 1 Type 1 Life 20yrs less Life 20yrs less Type 2 Life 10yrs less Type 2 Life 10yrs less

live in N.America live in N.America 2-

• 4 fold greater risk of

4 fold greater risk of stroke and heart stroke and heart disease disease 65% of deaths from 65% of deaths from CVS disease CVS disease