Endocrine, DM and renal Care Block 1

Diabetes Mellitus

Ali Salim Rasheed

 Why C peptide is used as marker for insulin secretion rather than insulin?
- Measurement of C-peptide can be used to assess endogenous
insulin secretory capacity , C-peptide negativity (indicating complete
insulin deficiency) , and it is not metabolized by liver .

 Is there gender predilection for DM?

- The prevalence is similar in men and women throughout most age
ranges.

 What is behind the global pandemic of DM?

- This global pandemic principally involves type 2 diabetes, the
prevalence of which varies considerably around the world, being
associated with differences in genetic as well as environmental
factors such as greater longevity, obesity, unsatisfactory diet,
sedentary lifestyle, increasing urbanisation and economic
development.

 Mention examples of pancreatic and endocrine diseases that cause DM?

- Pancreatic disease (e.g. pancreatitis, pancreatectomy,
neoplastic disease, cystic fibrosis, haemochromatosis,
fibrocalculous pancreatopathy)
- Excess endogenous production of hormonal antagonists to insulin,
e.g. Growth hormone – acromegaly , Glucocorticoids – Cushing’s
syndrome , Glucagon – glucagonoma , Catecholamines –
phaeochromocytoma , Thyroid hormones – thyrotoxicosis .

 Which lab. test could confirm the Dx of T1DM?

- The 2011 American Association of Clinical Endocrinologists (AACE)
guidelines note that to help distinguish between the 2 types in
children, physicians should measure insulin , C-peptide levels and
immune markers (eg, glutamic acid decarboxylase [GAD]
autoantibodies), as well as obtain a detailed family history.

 Why T1DM must be differentiated from T2DM?

- Because in patients with suspected type 1 diabetes, urgent
treatment with insulin is required and oral agent not beneficial .
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 Why diabetic ketoacidosis (DKA) is rare in T2DM?

- DKA results from relative or absolute insulin deficiency combined
with counterregulatory hormone excess (glucagon, catecholamines,
cortisol, and growth hormone). Both insulin deficiency and glucagon
excess, in particular, are necessary for DKA to develop. In type 2
diabetes, insulin production is present but is insufficient to meet the
body's requirements as a result of end-organ insulin resistance.

 What are types of insulin resistance?

- The syndromes of insulin resistance actually make up a broad

clinical spectrum, which includes obesity, glucose intolerance,
diabetes, and the metabolic syndrome, as well as an extreme
insulin-resistant state. Many of these disorders are associated with
various endocrine, metabolic, and genetic conditions. These
syndromes may also be associated with immunological diseases and
may exhibit distinct phenotypic characteristics.

 What is the cause of polyuria in DM?

- Polyuria in diabetes mellitus is due to osmotic diuresis from
excretion of excess glucose. Water is drawn out by osmosis due to
the high filtration of glucose in the kidney. Polyuria in this setting
indicates symptomatic hyperglycaemia.

 What are the causes of weight loss with good appetite?

- DM .
- Hyperthyroidism .
- Malabsorption syndrome .
- Lymphoma .

 Are the symptoms necessary for diagnosis of DM ?

- In asymptomatic patients, two diagnostic tests are required to
confirm diabetes.

 What is HbA1c?
- Glucose in the blood will react with the terminal valine of the
haemoglobin molecule to produce glycosylated haemoglobin
(HbA1c). The percentage of HBA1c is a good indicator of how
effective blood glucose control has been. As RBCs normally spend
~3 months in the circulation the %HbA1c is related to the average
blood glucose concentration over the preceding 2-3 months.
- Poorly controlled diabetics can have a HbA1c value above 10%.
- Hemoglobin A1c (%) : normal ( ≤5.6 ) , pre-diabetes ( 5.7-6.4 ) , DM
: ( ≥6.5 )
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 How do you prepare patient for OGTT?

- Unrestricted carbohydrate diet for 3 days .
- Fasted overnight for at least 8 hrs .
- Rest for 30 mins .
- Remain seated for the duration of the test, with no smoking .

 What is the definition of pre-diabetes?

- ‘Pre-diabetes’ is classified as:
- Impaired fasting glucose = fasting plasma glucose ≥ 6.0
(108 mg/dL) and < 7.0 mmol/L (126 mg/dL)
- Impaired glucose tolerance = fasting plasma glucose < 7.0 mmol/L
(126 mg/dL) and 2-hr glucose after 75 g oral
glucose drink 7.8–11.1 mmol/L (140–200 mg/dL) .

 Why consumption of complicated carbohydrate is encouraged in diabetic

patient ?
- Consumption of foods with a low GI is encouraged because they
produce a slow, gradual rise in blood glucose. Examples
include starchy foods such as basmati rice, spaghetti, porridge,
noodles, granary bread, and beans and lentils.

 What are the food items rich in polyunsaturated fats?

- omega-3 (fish oil) .
- vegetable oils .
- nuts .

 What is the benefit of vegetables in the diet of diabetic patients?

- Hypoglycemic effect … increase transit time …. Reduce absorption of
dietary glucose

 What is ADA and EASD?

- American Diabetes Association .
- European Association for the Study of Diabetes .

 What are the targets of good diabetic control?

- Blood glucose targets vary according to individual circumstances,
but, in general, pre-meal values between 4 and 7 mmol/L (72 and
126 mg/dL) and 2-hour post-meal values between 4 and 8 mmol/L
represent optimal control.

 What are the indications for use of aspirin and statin in diabetic patients?
- the use of aspirin for secondary prevention of coronary events and
the consideration of aspirin use in diabetic individuals with an
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increased cardiovascular risk ( hypertension, smoking, family

history, albuminuria, or dyslipidemia).

- The aspirin dose (75–162 mg) is the same as that in nondiabetic

individuals.
- Aspirin therapy does not have detrimental effects on renal function
or hypertension, nor does it influence the course of diabetic
retinopathy.
- Statins are the preferred drugs of choice for lowering cholesterol
and CV risk in patients with diabetes, aiming for targets of total
cholesterol < 4 mmol/L and LDL - cholesterol < 2 mmol/L.

 How can you differentiate DKA from hypoglycemia in a confused diabetic

patient?
- Hx (age (DM I – DM II –insulin – missed meal - …. ) , Examination ,
Ix ( blood glucose level , ….) .

 Why do we use GW 5% in spite of persistent hyperglycemia?

- When the blood glucose has fallen, 10% dextrose infusion is
introduced and insulin infusion continued to encourage glucose
uptake into cells and restoration of normal metabolism.
(extracellular hyperglycaemia rather than intracellular )

 What is the risk of rapid potassium infusion?

- The risk of electrolyte-induced cardiac arrhythmia.
- Cardiac rhythm should be monitored in severe DKA .

 What is the underlying pathology for macrovascular and microvascular

complications in DM ?
- The histopathological hallmark of diabetic microangiopathy
is thickening of the capillary basement membrane, with associated
increased vascular permeability, which occurs throughout the body.
- The development of the characteristic clinical syndromes of
diabetic retinopathy, nephropathy, neuropathy and accelerated
atherosclerosis is thought to result from the local response to
generalised vascular injury. For example, in the wall of large vessels,
increased permeability of arterial endothelium, particularly when
combined with hyperinsulinaemia and hypertension, may increase
the deposition of atherogenic lipoproteins.

 Mention the causes of peripheral neuropathy ?

- Genetic disease
o Charcot-Marie-Tooth (CMT) disease
- Drugs
o Amiodarone .
 Endocrine, DM and renal Care Block 5

o Antibiotics (dapsone ,isoniazid ,metronidazole, ethambutol)

o Antiretrovirals
o Chemotherapy (cisplatin, vincristine, thalidomide)
o Phenytoin
- Toxins
o Alcohol
o Nitrous oxide (recreational use)
- Vitamin deficiencies
o Thiamin
o Pyridoxine
o Vitamin B12
o Vitamin E
- Infections
o HIV
o Leprosy
o Brucellosis
- Inflammatory
o Guillain–Barré syndrome
o Chronic inflammatory demyelinating
polyradiculoneuropathy
o Vasculitis (polyarteritis nodosa, granulomatosis with
polyangiitis (also known as Wegener’s granulomatosis),
rheumatoid arthritis, SLE)
o Paraneoplastic (antibody-mediated)

- Systemic medical conditions

o Diabetes ( the most common )
o Renal failure (Approximately 60% of patients with renal
failure develop a polyneuropathy characterized by length-
dependent numbness, tingling, allodynia, and mild distal
weakness.)
o Sarcoidosis
- Malignant disease
o Infiltration
- Others
o Paraproteinaemias
o Amyloidosis
o Critical illness polyneuropathy/myopathy .

 How can you differentiate between somatic and neuropathic pain?

- Nociceptive pain : resulting from activity in neural pathways
caused by potentially tissue-damaging stimuli. It tends to be
localized, aching, throbbing, and cramping.
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- The classic example is bone metastases.

- Neuropathic pain : caused by a primary lesion or dysfunction in the
peripheral and/or central nervous systems . It is described by
patients as burning, electrical, or shock like pain , may be triggered
by very light touch . On examination, a sensory deficit is
characteristically present in the area of the patient's pain.
- Classic examples are post stroke pain, herpetic neuralgia , and
diabetic neuropathy .

 What are the clinical features of 3rd nerve palsy?

- Involved eye is deviated down and out (divergent squint)
- Ptosis.
- Pupillary dilatation
- Paralysis of accommodation causes blurred vision for near
objects.
 What is the underlying etiology for radiculopathic pain associated with
skin rash?
- Herpes zoster infection ( shingles )

 What are the predisposing factors for diabetic foot?

- trauma .
- presence of neuropathy and/or peripheral vascular disease .
- infection occurring as a secondary phenomenon following
disruption of the protective epidermis.

 What are the effects of pregnancy on patient with DM?

- Change in eating pattern due to nausea/vomiting in early .

pregnancy; delayed gastric emptying and reflux oesophagitis
in later pregnancy .
- Increasing insulin dose (insulin sensitivity declines by ∼ 50%)
- Need for tight glycaemic control .
- Increasing risk of hypoglycaemia .
- Risk of deterioration of retinopathy .
- Risk of deterioration of renal function in women with
Nephropathy .
- Proketotic state – vulnerable to DKA .
- Decreased renal threshold to glucose predisposing to urinary
infection .

 What are the effects of maternal diabetes on pregnancy ?

- Need for preconception care .
 Endocrine, DM and renal Care Block 7

- Increased congenital malformations .

- Increased risk of miscarriage and late intrauterine death .
- Need for regular surveillance and ultrasound monitoring .
- Increased risk of pre – eclampsia .
- Macrosomia and consequent difficult delivery .
- Increased early delivery and caesarean section rate .
- Increased perinatal mortality.

 Pre - pregnancy care

Give advice and information on:
- The risks of diabetes in pregnancy and how to reduce them
with good glycaemic control .
- Diet, bodyweight and exercise, including weight loss for
women with a BMI over 27 kg/m 2 , smoking cessation and
alcohol avoidance .
- Hypoglycaemia and hypoglycaemia unawareness and
avoidance .
- Pregnancy - related nausea/vomiting and glycaemic control
- Retinal and renal assessment .
- When to stop contraception .
- Taking folic acid supplements (5 mg/day) from preconception
until 12 weeks of gestation .
- Review of, and possible changes to, medication (stop statins
and any antihypertensive medication contraindicated in
pregnancy), glycaemic targets and self - monitoring routine .
- Frequency of appointments and local support, including
emergency telephone numbers .