Diabetes Mellitus (DM) - Dr Hiren Patt

Diabetes Mellitus (DM) - Dr Hiren Patt

What is DM? FPG 2-Hour PG on OGTT Diabetes Mellitus Diabetes Mellitus 126 mg/dl 100 mg/dl Impaired Fasting Glucose 200 mg/dl 140 mg/dl Impaired Glucose Tolerance Normal Normal

What is DM? HbA1c Random plasma glucose 6.5 % 5.7 % Diabetes Mellitus Impaired Fasting Glucose 200 mg/dl + Symptoms Diabetes Mellitus Normal Normal

What is IFG/IGT? FPG 2-Hour PG on OGTT Diabetes Mellitus Diabetes Mellitus 126 mg/dl 100 mg/dl Impaired Fasting Glucose 200 mg/dl 140 mg/dl Impaired Glucose Tolerance Normal Normal

Classification of DM Type 1 DM Type 2 DM Other specific type of DM Maturity onset DM of the young Neonatal DM Pancreatic causes Drug induced Gestational DM (GDM)

Natural History: Type 1 DM

Honeymoon Phase: Type 1 DM

Risk Factors: Type 2 DM IFG/IGT Obesity high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) Family history of Type 2 DM H/O GDM or PCOD

Natural History: Type 2 DM

Type 1 DM Younger Lean Family history: rare Antibodies: positive Insulin deficiency Beta cell destruction Low insulin & C peptide levels since beginning DKA: common Type 2 DM Older Obese Family history: common Antibodies: negative Insulin resistance & Beta cell secretory defect High Insulin & C peptide initially DKA: rare

Gestational DM DM diagnosed in 2 nd or 3 rd trimester which is not clearly Type 1 or Type 2 DM

Clinical Features

Presenting Events Unexplained weight loss Osmotic symptoms (polyuria, polydipsia) Type 1 DM DKA Type 2 DM Chronic Complications

Autoimmune disorders (Type 1 DM) Goitre (Hypothyroidism/ Grave s disease) Vitiligo

Insulin Resistance (Type 2 DM) Acanthosis nigricans Skin tags

Complications Acute complications: Ketoacidosis Hyperglycemic hyperosmolar nonketotic syndrome Hypoglycemia Chronic complications: Disorders of the microcirculation Neuropathies Nephropathies Retinopathies Macrovascular complications (IHD, CVA, PVD) Foot ulcers Infections

DKA/HHS: Pathogenesis

Management of DKA Adequate hydration Insulin infusion (iv) Once ketones disappear, overlap and shift with MDI insulin (sc) Prevention: No skipping of insulin Adequate hydration and monitoring of urine ketones and sugars during stress/infection

Chronic Complications Conduit Artery Resistance Precapillary Capillaries Arterioles Arterioles Atherosclerosis Hypertension Retinopathy Neuropathy Nephropathy

Predictors Duration of DM Control of DM HT Dyslipidemia Smoking? Genetic

Stages of Diabetic Nephropathy

Plasma Glucose as Independent Risk Factor Andersson, DK et al. Diabetes Care 18: 1534-1543

Risk of MI in Diabetes Haffner, SM et al NEJM: 339: 229-234

Screening: Chronic Complications Type 1 DM: After 5 years of diagnosis Type 2 DM: At the time of diagnosis Annually Fundus Urine albumin:creatinine ratio Creatinine, LFT Complete lipid profile Foot examination

Infections: Common Why? Vascular disease Neuropathy (unrecognised injury) Hyperglycemia Altered neutrophil function (particularly adherence, chemotaxis, and phagocytosis)

Which infections? Community acquired pneumonia Acute bacterial cystitis Acute pyelonephritis Emphysematous pyelonephritis Perinephric abscess Fungal cystitis Necrotizing fasciitis Invasive otitis externa Rhinocerebral mucormycosis Emphysematous cholecystitis Skin & Soft tissue infections TB

Case Capsule 24 years / Female Pregnant, 2 months of amenorrhea Asymptomatic No Family history of DM BMI: 24 kg/m2 Oral Glucose Tolerance Test: Fasting: 120 mg/dl 1 hour: 240 mg/dl 2 hours: 220 mg/dl HbA1c: 6.6 %

Diagnosis? Type 1 DM Type 2 DM GDM

Case Capsule 10 years, male child Type 1 DM, since 2 years Inj. HI (Regular) 5-5-5 & Inj. Glargine 0-0-12 FBS: 200 Inj. Glargine 0-0-15 FBS: 240 Where is the problem?

Somogyi and dawn phenomenon