Aproach to Diabetes Mellitus

Kurniyanto
Department of Internal Medicine
FK UKI
Introduction
• Diabetes mellitus
• chronic progressive metabolic disease characterized by elevated blood sugar
• Etiology
• Insulin resistance
• Insulin deficient
• Combination
• Hallmark of diabetes
• Maintenance blood glucose and prevent complications
Prevalence of Diabetes 1980-2014
• Who is most affected ?
• Obesity
• Mean age 46 yo
• Men < 60 yo are > older women
• American-Indians
• Whom to screen ?
• Adullts ≥ 45 yo
• Overweight or obese
• Hypertension
• CVD/CAD
• History of GDM
• PCOS
• Physical inactivity
• Low HDL and/or high TG
• Patients with medication increase risk of DM
• Children > 10 yo with 1st or 2nd degree relative of DM, sign of insulin resistance,
maternal history of DM, ethnic group
Pathogenesis

Omnious Octet
Many “face” of diabetes patient
Approach to DM
• Classic symptoms • Gradual onset
• Polyuria • Signs
• Polydipsi • Normal to various according to
• Polyphagy affected organ
• Weight loss
• Others symptoms • Kidney  oliguria, proteinuria,
• Fatigue edema
• Paresthesia • Heart  chest pain, dyspnea
• Pruritus • Brain  stroke
• Blurred vision • PAD  pulselessnes
• Erectile dysfungsion • Neuropathy  sensory loss
• Frequent infections • Wound
• Bowel or bladder dysfunction
• Acute complications
• Extreme hyperglycemia : KAD and
HHS
• Hypoglycemia
• Risk of DM • Associated conditions
• Prediabetes • Hypertension
• Obesity • Dyslipidemia
• Metabolic syndrome • CAD
• PCOS
• Increase risk of cancer
• GDM
• Smoking • Fatty liver disease
• Poor diet (western pattern diet) • HIV
• Lack of exercise
• Race
• Socioeconomic status
• Evaluate
• Alternative medicine
• Medication taking eg : Thiazide, corticosteroid, niacin, thyroid hormone,
phenytoin, IFN, protease inhibitor
• Ask about history of
• Hypoglycemia episode
• Eating patterns, nutritional status and education
• Use of technology assisted tools
• Hypertension or abnormal lipid level
• Renal disease, eye disease, neuropathy
• CAD, CVD
• Gestational DM, PCOS
• Family history
• First degree relative of diabetes
• Ethnicity (African-American, native American, latino, Asian-American, pacific
islander)
• Social
• Tobacco use
• Alcohol and substance use
• General Physical
• Asses height, weight and BMI
• Hypertension
• Orthostatic hypotension and/or resting tachycardia
• Skin
• Acanthosis nigricans
• Insulin injection site  lypodysthrophy
• Periungual telangiectasia
• Diabetic thick skin
• Skin tags
• Diabetic dermopathy
• Eye • Abdomen
• Funduscopic exam  retinopathy • Hepatomegaly in NAFLD
• Hearing • Extremity
• Impairment • Skin lessions  DFU
• Neck • Palpate dorsalis pedis and posterior
tibial pulse
• Carotid bruit  risk of stroke • Test for sensation
• Cardiac • APR and KPR
• Signs of heart failure • Neuropathy
• Lung • Semmes-Weinstein monofilament
• Signs of lung edema exam
• Tuberculosis • Symetric distal nerve dysfunction
(sensory > motoric)
Classic signs and symptoms

Plasma Blood Glucose

Others testing
• LDL, HDL, cholesterol and tryglicerides
• Liver function test (transaminases)
• Serum creatinine
• Urine protein
• Electrocardiography
• Echocardiography
• Ankle brachial index
Complications
• Acute complication
• Hypoglycemia
• DKA
• HHS
• Chronic complications
• Microangiopathy : neuropathy, retinopathy, nephropathy, DF, dermopathy
• Macroangiopathy : CVD, CAD, PAD
Management
• Education
• Glycemic goals
• A1c < 7%
• Preprandial glucose 80-130 mg/dl
• Post prandial glucose < 180 mg/dl
• Lifestyle modification : diet and exercise
• Medications
• Oral agents
• Insulin
• GLP-1 agonis
• Management comorbidities
Question please