Diabetes mellitus - diagnosis, classification and acute complications. David Karásek 3rd Department of Internal Medicine University Hospital Olomouc

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1 Diabetes mellitus - diagnosis, classification and acute complications David Karásek 3rd Department of Internal Medicine University Hospital Olomouc

2 Diabetes mellitus is a group of metabolic diseases, characterized by hyperglycemia due to impaired insulin secretion, insulin action (insulin resistance), or both

3 Classification and screening of diabetes Classification of diabetes T1DM (6,8%) T2DM (91,7%) Other specific types of diabetes (1,5%) Gestational diabetes 5-17% Active screening for diabetes (glucose in venous or capillary blood, HbA1C) - 1 per 2 years (over 40 years of age) - 1 per year in high risk individuals (CVD, HLP, HT, obesity, PCOS, GDM, prediabetes, positive FH of DM, delivery of the fetus > 4 kg) or in patients with obvious signs of DM

4 Diagnosis of DM and disorders of glucose homeostasis Diabetes mellitus a) presence of diabetic symptoms + random glycemia* 11.1 mmol/l b) fasting glycemia* 7.0 mmol/l c) glycemia* in the 120. minute of ogtt 11.1 mmol/l d) HbA1C 48 mmol/mol ( 4.8% - IFCC, 6.5% -DCCT) Prediabetes a) fasting glycemia* 5.6 mmol/l and < 7.0 mmol/l b) glycemia* in the 120. minute of ogtt 7.8 mmol/l and < 11.1 mmol/l c) HbA1C 39 mmol/mol and < 48 mmol/mol ( 3.9% and < IFCC, 5.7% and < 6.5% - DCCT) * - glucose in venous plasma

5 Differential diagnosis of diabetes T1DM sudden appearance of diabetic syndrome (polyuria, polydipsia, weight loss), ketoacidosis lower age other autoimmune diseases (AIT, celiac disease, etc.) low C-peptide, autoantibodies positivity (anti-gad, anti-ia-2, anti-2β) T2DM asymptomatic phase, slow progression, no ketoacidosis older age obesity, and other symptoms of MS chronic complications at time of diagnosis high C-peptide, autoantibodies negativity

6 Other specific types of diabetes MODY (maturity-onset type diabetes of the young) about 3-5% of DM year of age, usually without insulin treatment, no ketoacidosis, negative markers of autoimmunity (auto-antibodies, HLA antigens), AD inheritance: the victim is in every generation Pancreatic diabetes chronic pancreatitis, pancreatic cancer, trauma, pancreatectomy, cystic fibrosis, hemochromatosis Endocrine diabetes Cushing's syndrome, pheochromocytoma, glucagonoma, somatostatinoma, hyperthyroidism, acromegaly, hyperparathyroidism, VIPoma, Conn's syndrome DM induced by drugs and chemicals vacor, pentamidine, streptozocin, diazoxide, cortisone, thyroxine, adrenergic agonists, thiazides, beta-blockers, nicotinic acid, statins Genetic syndromes and others Rabson-Mendenhall's syndrome, Down's syndrome, Turner's syndrome, Klinefelter's syndrome, Laurence-Moon-Biedl's syndrome, Prader-Willi's syndrome

7 Acute complications of diabetes Hypoglycemia Hyperglycemia with ketoacidosis Hyperosmolar hyperglycemic coma Lactic acidosis in connection with diabetes

8 Hypoglycemia in connection with DM Causes: Absolute or relative excess of insulin or PAD (sulfonylureas), noncompliance, renal insufficiency, lack of glucagon (pancreatic diabetes), beta-blockers Absolute or relative deficiency of carbohydrates in the diet, alcohol drinking Inadequate physical activity Definition: Laboratory findings of low blood glucose (< 3.3 mmol/l) Clinical picture of hypoglycemia Disappearance of symptoms after administration of glucose

9 Clinical picture of hypoglycemia Activation of sympathoadrenal system: trembling, sweating, tachycardia, anxiety, nervousness, hunger Neuroglycopenia (2,8-3,0 mmol/l): weakness, fatigue, nausea, headache, visual impairment and hearing impairment, impaired motor skills (stroke-like), convulsions, impaired consciousness Asymptomatic or symptomatic hypoglycemia: mild hypoglycemia (patient can handle itself) severe hypoglycemia (required outside assistance) apparent hypoglycemia (> 3.3 mmol/l, hypoglycemic threshold) Hypoglycemia-associated autonomic failure ( hypoglycemic threshold, altered perception of hypoglycemia and secretion of counter-regulatory hormones-adrenaline, glucagon)

10 Treatment for hypoglycemia Treatment of mild hypoglycemia: g of simple sugars (2-3 cubes of sugar, 1 glass of juice, Coca-Cola) eventually after 5-10 min to repeat Treatment of severe hypoglycemia: ml of 40% glucose IV, if not possible (not IV access, aggressive patient, family members) -1 mg of glucagon IM Hospitalization: persistent impairment of consciousness, recurrent hypoglycemia (PAD i.v. infusion with glucose), impossible control of another person, self harm

11 Hyperglycemia with ketoacidosis-1 Causes and mechanism of ketoacidosis: Lack of insulin T1DM (first manifestation of diabetes in third of diabetic children), treatment errors, stress and acute intercurrent disease overproduction of catecholamines Hyperglycemia + FFA (lipolysis) Glucagon excess ( catecholamines) FFA oxidation and ketogenesis Hyperglycemia osmotic diuresis, ion loss and dehydration Ketogenesis metabolic acidosis Clinical picture: Progressive polydipsia, polyuria, dehydration (weakness, orthostatic hypotension) Nausea, vomiting, abdominal pain (pseudoperitonitis diabetica) Dyspnoea (Kussmaul breathing, breath smells of acetone) Disorder of consciousness or coma

12 Hyperglycemia with ketoacidosis-2 Laboratory findings: metabolic acidosis, anion gap (>16mmol/l), hyperglycemia, deficit of K + (even in case of hyperkalemia), deficit of PO 4+ (Mg +, Ca + ), dehydration( urea, creatinine, RBC, Na + ), TG, CK, AMS BC leukocytosis Ketones in serum and urine Therapy: Insulin IV (HM, or short-term analog): bolus 8-12 IU IV (0.1 IU/kg), cont. IV 4-12 IU/h (0.1 IU/kg) Supplementation of fluids deficit: FR 1/ ml/h, 500 ml/h for 4-6 h,... (if blood glucose drops to 15 mmol/l) G5% Supplementation of K +, PO4 + Bicarbonate (ph<7,0): 1-2mmol/kg (4,2% NaHCO ml)

13 Hyperglycemic (hyperosmolar) coma Causes and mechanism of hyperosmolarity: Dehydration (infection, stroke, MI, dementia, social isolation) + hyperglycemia (relative lack of insulin, mostly T2DM, no ketogenesis, older individuals) Hyperglycemia osmotic diuresis, ion loss and dehydration Clinical picture: Progressive polydipsia, polyuria, dehydration (weakness, orthostatic hypotension), disorder of consciousness, convulsion + symptoms indicating causes Laboratory findings: Hyperglycemia, hyperosmolarity (2x (Na + + K + ) + glycemia + urea), Metabolic acidosis ( lactate, renal failure) + findings indicating causes

14 Hyperglycemic coma Therapy: Supplementation of fluids deficit (up to 10l): FR 1/1 (FR ½, if blood glucose drops to 15 mmol/l G5%) x heart failure Supplementation of K +, PO4 + x renal failure Insulin IV (HM, or short-term analog): bolus 8-12 IU IV (0.1 IU/kg), cont. IV 4-12 IU/h (0.1 IU/kg) LMWH, ATBs, PPIs Complications (up to 50% mortality): Renal failure, DIC, MOFS, infections, thrombembolic disease Iatrogenic complications of rapid compensation brain edema, heart failure

15 Lactic acidosis in diabetes Causes: A-hypoxia (NYHA III-IV),B - biguanides (metformin + non-observance of contraindications renal or hepatic insufficiency) Clinical picture and laboratory findings: underlying disease + metabolic acidosis (nausea, vomiting, Kussmaul breathing disorder of consciousness, hypotension, bradycardia or tachycardia) lactate, metabolic acidosis + other findings according to causes Therapy: treatment of the underlying cause of hypoxia (O2, ventilation) treatment of acidosis bicarbonate, hemodialysis

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