HIHIM Clinical Cocepts for Managers 7/31/2009. Fernando Vega, MD 1

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1 Fernando Vega, MD HIHIM 409 July 31, 2008 Hyperglycemia characterized by relative or absolute lack of insulin secretion Varying degrees of insulin resistance Often associated with symptoms: polyruia, polydipsia, unexplained weight loss 2 Insulin Enhances peripheral glucose uptake Inhibits breakdown of liver glycogen Enhances storage of glucose as glycogen Increases protein synthesis Increases triglyceride storage Hyperglycemia characterized by relative or absolute lack of insulin secretion Varying degrees of insulin resistance Often associated with symptoms: polyruia, polydipsia, unexplained weight loss 3 4 Normal fasting glucose < 100 Normal postprandial glucose <140 Fasting 2 hours pp Normal <100 <200 IFG IGT Diabetes < 126 > Fernando Vega, MD 1

2 Classification of Diabetes Type I Destruction of pancreatic beta cells leading to absolute insulin deficiency Type II Variable degrees of insulin deficiency and resistance Terminology Gestational diabetes Diabetes secondary to other conditions Type 1 diabetes Juvenille Abrupt onset Family history Autoimmune Ketones Total insulin def, Islet cell AB pos HLA DR3 DR4 Insulin dependent Type 2 diabetes Older age Slow onset Family history Not autoimmune No ketones Partial Insulin def/resistance Insulin requiring Diet/OHA 7 8 Secondary Diabetes Steroids Thiazide Diuretics Drugs for HIV Pancreatectomy Acute pancreatitis Chronic Pancreatitis Haemachromatosis Cystic Fibrosis Cushings Disease Acromegaly MODY DIDMOAD Prevalence: 7% of the US population has diabetes ½ of them are undiagnosed The prevalence is increasing 9 10 Typical Presentations: Patient with diabetic symptoms Patient with another illness Discovery on routine screening Clinical Management Acutely In office Inpatient Assessment of progression Fernando Vega, MD 2

3 Treatments for Hyperglycemia Clinical Management Long Term Glycemic control Oral hypoglycemics Insulin Blood pressure control Lipid control Diet Metformin Sulphonylureas Acarbose Thiazolidinediones Netaglinide/Repag. Regular Insulin Long acting Insulin Analogue insulins Mixed insulins Other treatments Anti-hypertensives Statins/fibrates Aspirin ACE inhibitors ARBs Treat to Target HbA1C < 7% BP < 140/80 Cholesterol <5 mmol/l HDL-C >1mmol/l Triglycerides <1.5mmol/l Clinical Course of Diabetes Immediate consequences Early consequences Clinical Course of Diabetes - Immediate consequences Visual blurring Hypoglycemic episodes Weight changes Late consequences Fernando Vega, MD 3

4 Clinical Course of Diabetes - Early consequences Tendency to yeast infections Clinical Course of Diabetes - Late consequences Microvascular Disease: Nephropathy Retinopathy Atherosclerosis Coronary artery Peripheral Vascular Disease Nephropathy Peripheral Neurop Femoral Amyotrophy Mononeuritis multiplex Autonomic Postural hypotension Diarrhoea Impotence Atonic bladder Sweating Loss of hypo. awarenes Diabetic glomerulosclerosis Microalbuminuria <300mg/l Proteinuria >300mg/l Nephrotic >3g/l Abnormal creatinine Glycaemic control BP control CAPD Transplantation Retinopathy Vascular Disease Background DR Pre-proliferative DR Proliferative DR Maculopathy Fluroscein angiography Laser Blood Pressure Lipids Glucose PVD CVD CAD Diabetes Hypertension Proteinuria Lipids Cigarettes Obesity Fernando Vega, MD 4

5 CAD CVD Angina MI Silent infarct CCF ECG Cardiac enzymes Troponin I Exercise stress test Echocardiography Angiography Angioplasty/CABG TIAs CVAs Dementia CT scan Carotid Dopplers Treat risk factors Carotid bypass surgery PVD Diabetic Foot Intermittent Claudication Cold Legs Pulseless Leg Foot Ulcers Gangrene Doppler Studies Duplex Scanning Angiography Angioplasty Treat risk factors PVD Charcot Arthropathy Ulceration MRI Angiography Clinical Management Anticipatory prevention Evaluation of Diabetic Complications Routine Eye exams Routine Foot exams Screening for microalbuminuria Screening for atherosclerosis / coronary heart disease Clinical Management Anticipatory prevention Reducing the risk for microvascular Disease Smoking cessation Aspririn Blood pressure control Dyslipidemia Fernando Vega, MD 5

6 Clinical Management Management of Complications Coronary Artery Disease - silent MI s require more vigilance Kidney disease - Prevention is the mainstay of treatment Eye disease diabetic retinopathy Economic/Social facts 1:14 adults By 2025 more people 1: worldwide will have 1:5 >75 diabetes than now live in N.America 1:3 Unaware of diagnosis 2-4 fold greater risk of Type 1 Life 20yrs less stroke and heart Type 2 Life 10yrs less disease 65% of deaths from CVS disease Fernando Vega, MD 6