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Biochemistry for medics
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Contents
1) Laboratory Diagnosis
o Urine Analysis
o Blood Biochemistry
o Immunological Assays
2) Management
o Management of type 1 DM
o Management of type 2 DM
3) Summary
URINE ANALYSIS
a) Detection of urinary glucose (Glucosuria)
o First-line screening test for diabetes
mellitus
o Normally glucose does not appear in urine
until the plasma glucose rises above 160-
180 mg/dl.
o In certain individuals due to low renal
threshold glucose may be present despite
normal blood glucose levels.
o Conversely renal threshold increases with
age so many diabetics may not have
Glycosuria despite high blood sugar levels. Positive
Benedict’s test
URINE ANALYSIS (Contd.)
o Detection of Glucosuria- A specific and convenient
method to detect glucosuria is the paper strip
impregnated with glucose oxidase and a chromogen
system (Clinistix, Diastix), which is sensitive to as little
as 0.1% glucose in urine.
o Diastix can be directly applied to the urinary stream,
and differing color responses of the indicator strip
reflect glucose concentration.
o Benedict’s and Fehling’s test can also detect
glucosuria.
Diastix-
Reagent strips
URINE ANALYSIS (Contd.)
b) Ketonuria
o Qualitative detection of
ketone bodies can be
accomplished by nitroprusside
tests (Acetest or Ketostix),
Rothera’s test etc.
oThese tests do not detect
Beta-hydroxy butyric acid,
which lacks a ketone group Positive
o Ketone bodies may be Rothera’s
test
present in a normal subject as
a result of simple prolonged
fasting. Ketostix-
Reagent
strips
URINE ANALYSIS (Contd.)
c) Microalbuminuria
o May be defined as an
albumin excretion rate
intermediate between
normality (2.5-25 mg/day)
and macroalbuminuria
(250mg/day).
oThe small increase in
urinary albumin excretion
is not detected by simple
albumin stick tests and
requires confirmation by
careful quantization in a
24 hr urine specimen.
URINE ANALYSIS (Contd.)
o The importance of micro-
albuminuria in the diabetic
patient is that it is a signal
of early reversible renal
damage.
o Performing an albumin-to-
creatinine ratio is probably
easiest.
o Microalbuminuria is a
common finding (even at
Gradation of turbidity is linked to
diagnosis) in type 2 protein concentration
diabetes mellitus and is a
risk factor for macro
vascular (especially
coronary heart) disease. Biochemistry For Medics
11/7/2013 7
BLOOD BIOCHEMISTRY
1) Blood Glucose Estimation
Choice of sample
• Plasma or serum from venous blood
samples has the advantage over
whole blood of providing values for
glucose that are independent of
Haemtocrit and that reflect the
glucose concentration to which body
tissues are exposed.
• Plasma and serum are more readily
measured on automated equipment,
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they are used in most laboratories.
BLOOD BIOCHEMISTRY
Choice of sample (contd.)
• If serum is used or if plasma is collected from
tubes that lack an agent to block glucose
metabolism (such as fluoride), samples should be
refrigerated and separated within 1 hour after
collection.
• The glucose concentration is 10–15% higher in
plasma or serum than in whole blood because
structural components of blood cells are absent.
(mg/dl)
Time in minutes
11/7/2013 Biochemistry For Medics 40
Management of Type 2 Diabetes
Mellitus
• Insulin Secretagogues are generally well tolerated.
• All of these agents, however, have the potential to
cause profound and persistent hypoglycemia, especially
in elderly individuals.
• Hypoglycemia is usually related to delayed meals,
increased physical activity, alcohol intake, or renal
insufficiency.
11/7/2013 Biochemistry For Medics 41
Management of Type 2 Diabetes
Mellitus
2) Biguanides
• Metformin is representative of this
class of agents.
• It reduces hepatic glucose production
through an undefined mechanism and
improves peripheral glucose utilization
slightly.
• Metformin reduces fasting plasma
glucose and insulin levels, improves the
lipid profile, and promotes modest
weight loss.
• The major toxicity of metformin, lactic
acidosis, can be prevented by careful
patient selection.
11/7/2013 Biochemistry For Medics 42
Management of Type 2 Diabetes
Mellitus
3) α-Glycosidase Inhibitors
o α -Glycosidase inhibitors (acarbose
and miglitol) reduce postprandial
hyperglycemia by delaying glucose
absorption; they do not affect
glucose utilization or insulin
secretion.
o These drugs, taken just before each
meal, reduce glucose absorption by
inhibiting the enzyme that cleaves
oligosaccharides into simple sugars
in the intestinal lumen.
o The major side effects (diarrhea,
flatulence, abdominal distention)
are related to increased delivery of
oligosaccharides to the large bowel
11/7/2013 Biochemistry For Medics 43
Management of Type 2 Diabetes
Mellitus
4) Thiazolidinediones
•Thiazolidinediones reduce insulin
resistance.
•Rosiglitazone, Pioglitazone belong
to this category.
•Thiazolidinediones promote a
redistribution of fat from central to
peripheral locations.
•Circulating insulin levels decrease
with use of the thiazolidinediones,
indicating a reduction in insulin
resistance
11/7/2013 Biochemistry For Medics 44
Management of Type 2 Diabetes
Mellitus
5) Insulin Therapy in Type 2 DM
o Insulin should be considered as the initial therapy in
type 2 DM, particularly in lean individuals or those with
severe weight loss, in individuals with underlying renal
or hepatic disease that precludes oral glucose-lowering
agents, or in individuals who are hospitalized or
acutely ill.
o Insulin therapy is ultimately required by a substantial
number of individuals with type 2 DM because of the
progressive nature of the disorder and the relative
insulin deficiency that develops in patients with long-
standing diabetes.
11/7/2013 Biochemistry For Medics 45
Summary Of Type 1 DM
1) Diabetes mellitus type 1 (Type 1 diabetes, IDDM, or juvenile
diabetes) is a form of diabetes mellitus that results from
autoimmune destruction of insulin producing beta cells of the
pancreas.
2) The classical symptoms of Type 1 diabetes are polyuria,
polydipsia, polyphagia and weight loss.
3) Type 1 diabetes is fatal unless treated with insulin.
4) Injection is the most common method of administering
insulin; insulin pumps and inhaled insulin has been available
at various times.
5) Diabetic keto acidosis is the commonest complication of
Type 1 DM.
11/7/2013 Biochemistry For Medics 46
Summary of Type 2 DM
1)Type 2 DM is characterized by impaired insulin secretion,
insulin resistance, excessive hepatic glucose production,
and abnormal fat metabolism.
2) While many patients with type 2 diabetes present with
increased urination and thirst, many others have an
insidious onset of hyperglycemia and are asymptomatic
initially.
3) Hyperglycemic hyperosmolar state (HHS) is an acute
complication of Type 2 diabetes. Chronic complications are
micro and macro vascular involving small and large blood
vessels respectively.
11/7/2013 Biochemistry For Medics 47
Summary of Type 2 DM(contd.)
4) Glucose lowering agents that either increase insulin
secretion, reduce glucose production, increase insulin
sensitivity, and enhance GLP-1 (Glucagon like peptide)
action are used to treat hyperglycemia.
5) The care of individuals with type 2 DM must also
include attention to the treatment of conditions
associated with type 2 DM (obesity, hypertension,
dyslipidemia, cardiovascular disease) and
detection/management of DM-related complications.
11/7/2013 Biochemistry For Medics 48
For further details
•Refer
A Case oriented Approach Towards
Biochemistry
•A Book Of Clinical Biochemistry-
Jay pee Brothers Medical
Publishers.
•http://www.jaypeebrothers.com/pgDetails.aspx?cat=s&book_id=978
11/7/2013 Biochemistry For Medics 49