Laboratory Diagnosis and Monitoring

Type 2 Diabetes Mellitus

Raja Iqbal Mulya Harahap

Dept/MS Clinical Pathology FMUP - RSHS
Introduction
• Diabetes mellitus is one of the chronic diseases that causes the
highest death in Indonesia.
• According to data from the Institute for Health Metrics and
Evaluation, diabetes is the 3rd highest cause of death in
Indonesia in 2019, namely around 57.42 deaths per 100,000
population.
• Data from the International Diabetes Federation (IDF) found that
the number of diabetes sufferers in 2021 in Indonesia has
increased rapidly in the last ten years.
• This number is estimated to reach 28.57 million in 2045 or 47%
greater than the number of 19.47 million in 2021.
Outpatient
• Name : Mr. K
• Age : 78 y.o
• Occupation : Jobless
• Marriage Status : Married
• Complaint :
Routine visit to PUSKESMAS for his hypertension and diabetes problem
Current Condition :
• Patients complain that they urinate frequently at night so that their
sleep quality is disturbed. Complaints of pain when urinating were
denied and the urine was not accompanied by mucus or blood. The
patient also complained of dark vision. The patient has a history of
glaucoma and cataracts. The patient has a history of three eye
operations, twice for glaucoma and once for cataracts. However, the
patient still cannot see clearly. The patient's wife said that it was
difficult for the patient to move because his vision and hearing had
decreased. Currently the patient is taking amlodipine 5 mg, ramipril
10 mg, and metformin 500 mg. Complaints of vomiting, sensory and
motor impairment, chest pain, shortness of breath, and leg edema
were denied. The patient stated that he sometimes smoked when he
was younger. Denied history of alcohol consumption.
 Past Medical History

2008 2009 2013 2014 2017 2019 2021

• Diabetes • Glaucoma • Glaucoma Hipertension Cataract Recurrent Recurrent
Mellitus Operation Operation Operation Glaucoma Glaucoma
• Glaucoma (1st) (2nd)
Family Medical History
• The patient's father has a history of diabetes mellitus. All of the
patient's siblings have diabetes mellitus (8 siblings). The patient's two
older brothers and three younger siblings have died due to
complications from diabetes mellitus. The patient's wife and second
child had a history of hypertension.
Physical Examination
• Height : 161 cm Weight : 55 kg
• BMI : 21.2 kg/m2

• BP : 143/74 mmHg
• PR:HR 90 x/minutes regular
• R : 18 x/minutes
• T : 37℃
Physical Examination
• Visus : OD = No light perception, OS = 1/∞
• Other physical examination within normal limit

Diagnosis
● E11.21 Type 2 diabetes mellitus with diabetic nephropathy →
21/11/2023
● I10 Essential (primary) hypertension
● H40.2 Primary angle-closure glaucoma
Current Therapy :
● Amlodipine 5 mg 1x1 pc malam
● Ramipril 10 mg 1x1 pc pagi
● Metformin 500 mg 3x1 ac
Definition of Diabetes Mellitus
group of disorders leading to a variety of pathophysiological alterations

The disordered carbohydrate metabolism that underlies diabetes

manifests as hyperglycemia

Medical condition by increasing blood glucose above normal value

caused by autoimmune destruction of the pancreatic islet b-cells,

rendering the pancreas unable to synthesize and secrete insulin or
results from a combination of insulin resistance and inadequate insulin
secretion

Type 2 diabetes is the most common form, accounting for 85% to 95% of
diabetes in developed countries.
Pathophysiology of Diabetes Mellitus

Roles of some organs in hyperglycemia

Classification of Diabetes Mellitus
Diagnosis of Diabetes Mellitus
Various complaints can be found in people with T2DM, such as:

• Classic complaints: polyuria, polydipsia, polyphagia and

unexplained decrease weight gain.

• Other complaints: weakness, tingling, itching, blurred eyes,

and erectile dysfunction in men, as well as vulvar pruritus in
women.
Laboratory Diagnosis of Diabetes Mellitus
The ADA proposes that all asymptomatic people 35 years of age or more
should be screened in a health care setting.

Screening by HbA1c, FPG, or 2-h OGTT is recommended for individuals

who are at high risk of diabetes.

Glucose should be measured in venous plasma when used for screening

of high-risk individuals

Blood for fasting plasma glucose analysis should be drawn in the morning
after the subject has fasted overnight (at least 8 h).

WHO also accepts measurement of glucose in capillary [skin puncture or

“fingerstick”] blood

Routine measurement of plasma glucose concentrations in a laboratory is

not recommended as the primary means of monitoring or evaluating
therapy in individuals with diabetes.
Blood glucose level as screening tools
Examination results that do not meet normal criteria or the criteria for DM
are classified into the prediabetes group Include:

• impaired glucose tolerance (IGT)

• impaired fasting plasma glucose (FPG)

+ HbA1c → 5,7-6,4%
Blood test level for diagnosing diabetes and
prediabetes
How to do OGTT:
Urine Glucose

Urine analysis is also done mainly to test glucose, protein, ketones etc
while routine checking up of patients.

Testing urine for glucose is inexpensive, noninvasive, and rapid.

Qualitative, semiquantitative, and quantitative methods are available to

measure glucose in urine
Ketone Testing
The ketone bodies, acetoacetate (AcAc) acetone, and b-hydroxybutyrate
(bOHB), are catabolic products of free fatty acids

widely used in the management of people with diabetes mellitus as adjuncts for
both diagnosis and ongoing monitoring of DKA.

who are prone to ketosis or treated with sodium–glucose cotransporter 2 [SGLT2]

inhibitors should measure ketones in urine or blood if they have unexplained
hyperglycemia or symptoms of ketosis and implement sick day rules and/or seek
medical advice if urine or blood ketones are increased
HEMOGLOBIN A1c --MONITORING
Is the specific glycated species that is modified by glucose on the N-terminal
valine of the hemoglobin β-chain.

Can be used as diagnostic test to diagnose diabetes or prediabetes

HbA1c should be measured routinely (usually every 3 months until acceptable,

individualized targets are achieved and then no less than every 6 months) in most
individuals with diabetes mellitus to document their degree of glycemic control.

ADA: The frequency of A1C testing should depend on the clinical situation,
the treatment regimen used and the clinician’s judgment
HEMOGLOBIN A1c
HbA1c measurement in individuals with disorders that affect red blood cell
turnover may provide spurious results regardless of the method used and glucose
testing will be necessary for screening, diagnosis, and management.

Assays of other glycated proteins, such as fructosamine or glycated albumin, may

be used in clinical settings where abnormalities in red blood cell turnover,
hemoglobin variants, or other interfering factors compromise interpretation of
HbA1c test results, although they reflect a shorter period of average glycemia
than HbA1c

HbA1c cannot be measured and should not be reported in individuals who do not
have HbA
Fructosamine
Other measurement in glucose control.

Reflect mean glycemia but over a much shorter time (15 to 30 days, reflecting the
turnover of albumin).

To evaluate glucose levels during the last 2-3 weeks

clinical utility of glycated proteins other than hemoglobin has not been clearly
established.

Further studies are also needed to determine measurements of advanced

glycation end products (AGEs) are clinically useful as predictors of risk for chronic
diabetes complications
Blood Glucose Monitoring
Glucose meters is Portable meters for measurement of blood glucose
concentrations are used in three major settings:

by people with diabetes acute and chronic

in everyday activities care facilities.
in outpatient clinics

Portable glucose meters should not be used in the diagnosis of diabetes, including
gestational diabetes mellitus

Glucose meters have limited if any documented role in screening for diabetes in
health care settings
Blood Glucose Monitoring
Frequent blood glucose monitoring (BGM) is recommended for all people with
diabetes who use intensive insulin regimens (with multiple daily injections or insulin
pump therapy) and who are not using continuous glucose monitoring (CGM)

Routine use of BGM is not recommended for people with type 2 diabetes treated
with diet and/ or oral agents alone.

Frequent use of BGM (or CGM) is particularly important for tight glycemic control
and avoidance of frequent hypoglycemia in type 1 diabetes.

The ADA Standards of Care suggests that nonroutine use of BGM is beneficial in
specific situations for some individuals with diabetes who are not using multiple
injections of insulin
Continuous Glucose Monitoring
CGM devices for home use include the ability to share data with a caregiver and or
the health care professional office via the cloud.

For individuals using CGM devices that require calibration by users, a blood glucose
meter should be used to calibrate the CGM.

Most CGM devices measure interstitial glucose using a glucose oxidase-

impregnated sensor, with electrochemical conversion into glucose concentrations
transmitted to a reader.
ANY QUESTION??
THANK YOU