Diabet es

Dr. Abhishek Bhargav
DNB (MED), MNAMS, FRSH (UK)

Consulting Physician &

WHAT YOU NEED TO KNOW ABOUT DIABETES

Commonly known as having Sugar or Madhumeh in Hindi. It is a disease in which the body either does not produce enough insulin or is unable to use the insulin

DIABETES

India …………….the Diabetic Capital of the world!!! It is estimated that 20.8 million people in US or 7% of the population has diabetes. Nearly 1/3 are unaware of it and are undiagnosed. Throughout the world, estimate is 150 million people have diabetes. 80 to 90% have Type 2 diabetes.

TYPES OF DIABETES:

TYPE 1 OR INSULIN DEPENDENT DIABETES. TYPE 2 OR NON INSULIN DEPENDENT OR MATURITY ONSET DIABETES. GESTATIONAL DIABETES

Type 1
   

Onset generally before 30 yrs Lean body habitus Requirement of insulin Propensity to develop ketoacidosis

Type 1 diabetes: before & after insulin

Type 1 diabetes: before & after insulin

Type 2
    

Generally after 30 yrs Usually obese (80%) Elderly may be lean May not require insulin initially Assoc Insulin resistance, HTN, CVD, Dyslipidemia, PCOS

TYPE 2 DIABETES
Co- morbid conditions:
    

Hypertension Dyslipidemia Athero sclerosis Coronary artery disease Peripheral vascular disease

Risk factors
        

Age 45 and over Family Hx ( first degree relatives with type 2) Ethnicity ( African American, Hispanic, South Asian, Pacific Islander, and Native American) Hx of gestational diabetes. Delivery of infants weighing 9 or more lbs. Poly Cystic Ovary Syndrome ( PCOS ) Overweight esp. with abdominal obesity Presence of cardio vascular disease, hypertension, impaired glucose Physical inactivity

Gestational Diabetes
Gestational Diabetes
temporary condition during pregnancy occurs in 3.5 - 3.8% of all pregnancies Increases risk for developing other types later in life for both mother and child

Gestational Diabetes
Risk Factors A previous diagnosis of GDM Age over 35 years Obesity A history of polycystic ovary syndrome Hirsutism (excessive body and facial hair) Acanthosis nigricans (a skin disorder characterized by the appearance of darkened patches of skin) Being a member of a population considered to be at high risk for diabetes, including women of Aboriginal, Hispanic, South Asian, Asian or African descent.

PRE DIABETES

 

Fasting Blood sugar 120 to 125 on 2 separate occasions 2 hour OGTT 140 to 199 Usually asymptomatic

SIGNIFICANCE OF DETECTING PRE DIABETES
 

 

Converts to diabetes in 4 to 7 years Can be delayed with life style changes and weight loss of 5 to 10% of body weight. Medication use may be indicated Early treatment can delay complications from diabetes

METABOLIC SYNDROME
  

Hypertension Dyslipidemia (low HDL, High TG) Waist measurement more than 35” for women and more than 40” for men For Asian women, waist more than 32.5” and higher than 35” for men Insulin resistance

Symptoms

    

May be asymptomatic Polyuria Polydypsia Polyphagia Weight gain Unexplained weight loss

Recurrent intermittent blurred vision. Generalized pruritis or vulvo vaginitis Peripheral neuropathy Sexual dysfunction such as ED. Recurrent skin infections

Diagnosis

Fasting plasma glucose 126 or above on at least 2 separate occasions. Random plasma glucose of 200 mg/dl or more on 2 separate occasions. Abnormal GTT (Plasma Glucose of 200 mg or more at 2 hours)

Tests
FBS/ PPBS  HbA 1c

Home blood glucose (HBG)  Urine testing  GTT

HbA1C - Use & Interpretation
       

Mean RBS 345 310 275 240 205 170 135

HbA1C 12 11 10 9 8 7 6

Treatment
Unfortunately, THERE IS NO CURE!

TREATMENT OPTIONS
LIFE STYLE CHANGES  EDUCATION  WEIGHT REDUCTION  DIET  DIET + EXERCISE  DIET + EXERCISE + MEDICINES

The multi-disciplinary team

The cornerstone in diabetes management:
       

Diabetologist Family Physician a specialised nurse a specialised dietician a chiropodist a specialised social worker a psychologist close collaboration with other relevant departments

Goals
 

HbA1c < 7 Post-prandial blood glucose values < 200mg/dl Pre-prandial blood glucose values < 140mg/dl Glycaemic goals less strict for very young children Goals realistic and individualised in puberty Prevent end organ damage

Diabetes education

Initial ‘survival’ education:
the causes of diabetes  OHAs  insulin management  injection technique  blood glucose measurements  acceptable blood glucose values  advice about hypo- and hyperglycaemic episodes  dietary advice

Diabetes education
The knowledge and skills of the patient should be regularly assessed  Re-education should be performed accordingly

Treatment
Education
Diabetes education is an important first step. All people with diabetes need to learn about their condition in order to make healthy lifestyle choices and manage their diabetes

Treatment
Lifestyle Management
Learning to reduce stress levels in dayto-day life can help people with diabetes better manage their disease.

Treatment
Physical Activity
Regular physical activity helps your body lower blood glucose levels, promotes weight loss, reduces stress and enhances overall fitness.

Effects of exercise
Increases insulin sensitivity  Improves the physical state  Reduces the risk of cardiac diseases  Reduces the risk of hypertension  Does not improve metabolic control  Increases the risk of hypoglycaemia

Treatment
Weight Management
Maintaining a healthy weight is especially important in the management of type 2 diabetes.

Food Guide Pyramid: Asian

Food Pyramid: Vegetarian

Treatment
Nutrition
What, when and how much you eat all play an important role in regulating how well your body manages blood glucose levels.

Diet: principles

Number of meals:
3 main meals  3 snacks  adapted to age, physical activity and insulin regimen

Energy intake:
1000 calories (4180 Kj) + 100 calories/year of age  50–55% of energy from carbohydrates  30% of energy from fat  15–20% of energy from protein

Carbohydrates

Glycaemic index (GI):
carbohydrate ranking system  based on post-prandial blood glucose response  low GI = slow, sustained blood glucose response (e.g. rice, pasta)  high GI = rapid and high blood-glucose response (e.g. white bread, candy/sweets, cornflakes, honey, sugar)

Dietary Recommendations
   

Fiber 20-35g/d Sodium <3g-4g/d Cholesterol <300mg/d Caloric sweeteners including sucrose acceptable Alcohol may increase the risk for hypoglycemia & hence if required should be taken with food

OHA
   

Insulin Secreatagogues Biguanides Alfa glucosidase inhibitors thiazolidinedones

Insulin Secreatagagues
 

Sulfonylureas Non sulfonylureas MOA: increase insulin SE: hypoglycemia, weight gain CI: renal/liver disease Expected reduction in HBA1c: 1-2%

   

Biguanides

     

MOA: decrease hepatic glucose production, weight loss, decrease insulin resistance Eg: metformin Expected reduction in HBA1c: 1-2% Dose: 500- 2000 mg/d ADV: no hypoglycemia SE: lactic acidosis, nausea CI: creat > 1.5mg/dl

Alfa Glucosidase Inhibitor
   

 

Decrease glucose absorption Eg: Acarbose, Miglitol, Voglibose Expected reduction in HBA1c: 0.5% ADV: no hypoglycemia, can use in Type 1 SE: GI flatulence CI: Renal/liver disease

Thiazolidenedione

  

 

MOA: decrease Insulin resistence, Increase Insulin utilization Eg: Rosiglitazone, Pioglitazone Expected reduction in HBA1c: 1-2% ADV: Decrease Insulin & Sulfo requirements SE: LFT derangement CI: CCF

DRUG Chlorpropamide Glibenclamide Glimepride Glipizide Glyclazide Repaglinide Nateglinide

DOSE (mg) 100-500 5-10 1-8 5-10 40-80 0.5-16 180-360

ACTION > 48 12-18 24 24 12-24 2-6 2-4

Problems with oral therapy

Only moderately effective (~1-2% lowering of HBA1c) Type 2 diabetes is a progressive disease

(~1% rise in HBA1c in 4 years)

Progressive addition of therapies necessary to achieve target blood sugars Specific problems:

Long acting sulphonylureas: prolonged hypoglycaemia Metformin: lactic acidosis

INSULIN

Insulin:
 

subcutaneous multiple dose rapid-acting insulin before meals, or combination of rapid- and intermediate-acting insulin twice daily insulin requirements may exceed 1.5–2 IU/kg/24 hours

Insulin
All children with Type 1 diabetes must have insulin  Consequences of long-term insulin omission:

growth retardation  delayed puberty  poor metabolic control  microvascular complications  short life expectancy  poor quality of life

Low C peptide levels
Give Insulin

Types Of Insulin
   

Short acting: 3-6hrs Intermediate acting: 10-18 hrs Long acting: 18-24 hrs Combinations: 10-16 hrs

Short Acting
   

Lispro :before or after meal Aspart:before or after meal Regular: 30 mins before meal Glulisine: launching shortly in India

Intermediate Acting
 

NPH Lente

Long Acting
  

Ultra lente Glargine: No peak Detemir

Combinations

75/25- 75% protamine lispro, 25% lispro 30/70- 70% NPH/aspart, 30% regular/aspart 50/50- 50% NPH/aspart, 50% regular/aspart

Insulin types and duration of action
Insulin preparation
Onset of action
(h or min) 30 min. 1–2 h 0.5–1 h 0.5–1 h 10–20 min.

Peak action
(h) 1–3 4–12 5–9 1–3 1–3

Maximal duration
(h) 6–8 18–24 18–24 18–24 3–5

    

Short-acting Intermediate-acting Premixed insulin 30/70 Premixed insulin 50/50 Rapid-acting insulin analogue

Short-acting insulin
Clear solution  Indications for use:

  

daily management of diabetes, alone or in combination with intermediate-acting insulin hyperglycaemia sick-day management intravenous therapy

Intermediate-acting insulin
Cloudy solution (should be thoroughly mixed before use)  Indications for use:

daily management of diabetes, alone or in combination with short-acting insulin

Pre-mixed insulin
Cloudy solution (should be thoroughly mixed before use)  Indications for use:

daily management of diabetes, alone or in combination with short-acting insulin

Storage of insulin
Stable at room temperature for weeks  Should not be exposed to temperatures > 25ºC or under freezing point  Unused vials and cartridges should be stored in the refrigerator  Should never be exposed to sunlight  Should never be frozen

Injection sites

Short acting insulin:

injected subcutaneously into the abdomen at a 45° angle

Intermediate-acting and pre-mixed insulins:

injected subcutaneously in the front of the thighs or into the buttocks at a 45° angle

Insulin absorption

Factors influencing insulin absorption:
injection site  injection depth  insulin type  insulin dose  physical exercise  skin temperature

Insulin requirements
Remission period  < 0.5 IU/kg/24 hours  Pre-pubertal period

0.6–1.0 IU/kg/24 hours 1.0–2.0 IU/kg/24 hours

Pubertal period

Long-term management
Twice daily or multiple insulin injections  Regular blood glucose measurements  At least 4 visits to out-patient clinic every year  HbA 1c measurements once every 3 months  Regular screening for diabetes related complications

Insulin regimens

Insulin regimens should be:
 

adjusted to age, maturity and motivation as simple as possible

Patients for multiple injection therapy should:
 

 

be selected carefully understand the relationship between insulin, food and physical exercise be motivated and have family support be willing to measure blood glucose several times each day be willing to inject insulin outside home also

Insulin regimens

Most widely used insulin regimens:
twice-daily injections, mixture short and intermediate, before breakfast and the evening meal  three daily injections, mixture short and intermediate before breakfast, shortacting before the evening meal and intermediate-acting before bed  short-acting insulin before main meals, intermediate before bed

Insulin distribution

Twice daily injection regimen:
  

2/3 of daily dose before breakfast, 1/3 before supper both 2/3 intermediate-acting and 1/3 short-acting insulin 40–50% before breakfast (2/3 intermediate- and 1/3 shortacting) 10–15% short-acting before supper 40% intermediate-acting before bed. 30–40 % (intermediate) before bed the rest (short-acting) before main meals

Three-times daily injection regimen:

 

Multiple injection regimen:
 

Insulin adjustments
Twice-daily injection regimen:
Blood glucose high: Dose of insulin to increase  Before breakfast or overnight Evening intermediate-acting  Before lunch Morning short-acting  Before dinner Morning intermediate-acting  Before bed Evening short-acting

Blood glucose low: Dose of insulin to decrease  Before breakfast or overnight Evening intermediate- acting  Before lunch Morning short-acting  Before dinner Morning intermediate-acting  Before bed Evening short-acting

Insulin adjustments
Three-times daily injection regimen:
Blood glucose high: Dose of insulin to increase  Before breakfast or overnight Evening intermediate- acting  Before lunch Morning shortacting  Before dinner Morning intermediate-acting  Before bed Evening short-acting

Blood glucose low: Dose of insulin to decrease  Before breakfast or overnight Evening intermediate- acting  Before lunch Morning shortacting  Before dinner Morning intermediate-acting  Before bed Evening short-acting

Insulin adjustments
Basal-bolus (multiple injection) regimen:
Blood glucose high: Dose of insulin to increase  Before breakfast or overnight Evening intermediateacting  Before lunch Morning short-acting  Before dinner Lunch time shortacting  Before bed Evening short-acting

Blood glucose low: Dose of insulin to decrease  Before breakfast or overnight Evening intermediateacting  Before lunch Morning short-acting  Before dinner Lunch time short

The remission phase
Duration from weeks to months  Shorter in young children  Decreasing insulin requirements < 0.5 IU/kg/24 hours  Once daily insulin injection is often sufficient in Type 1  Insulin injections should not be abandoned in Type 1

Complications
 

Acute Chronic

Acute Complications
 

Diabetic Ketoacidosis Hyper Osmolar Non Ketotic Coma

Diabetic Ketoacidosis

Characterised by:

absolute insulin deficiency  increased level of counter regulatory hormones

Etiology:

newly diagnosed  infections  insulin omission

Symptoms and signs
Dehydration  Vomiting  Loss of weight  Kussmaul respirations  Acetone smell  Impaired sensorium  Shock

Diagnosis
Clinical appearance  Hyperglycaemia  Ketonuria  Ketonaemia  Plasma bicarbonate < 22 mmol/l

What kills in DKA

Aspiration pneumonia Cardiac arrhythmias Doctors
  

ignoring key central cause over rapid correction of numbers forgetting potassium

Treatment
 Admission  IV  IV

in ICU

Fluids : Normal Saline Insulin electrolyte imbalance

 Antibiotics  Correct

Hyperosmolar non-ketotic coma (HONK)
     

Marked hyperosmolar hyperglycaemia > 500mg/d Relative insulin lack Hypernatremia In Type 2 Higher mortality!!! Treatment

careful rehydration - avoid rapid changes in osmolarity treatment of underlying disease

Chronic Complications
  

Micro vascular Macro vascular Others

Micro vascular
  

Retinopathy Neuropathy Nephropathy

Complications: eyes

Hyperglycaemic refractive changes (reversible) Diabetic retinopathy:  Microaneurysms  Blot haemorrhages  Hard exudates  Soft exudates  Proliferative retinopathy  Macular oedema (visual loss w/o retinal changes)

Normal Retina

Capillary damage
Microaneurysms

Hard exudates

Proliferation of new vessels

Haemorrhages

Diabetic retinopathy

Annual screening:
 

after 5 years’ diabetes duration in pre-pubertal children after 2 years’ diabetes duration in adults in Type 1 ophthalmoscopy fundus photography fluorescein angiography improved long-term metabolic control normalising arterial blood pressure laser therapy in case of proliferative retinopathy

Screening method:
  

Retinopathy treatment:
  

Complications: kidneys

Susceptible subgroup (20-30%)
  

Unusual in the absence of retinopathy Closely associated with hypertension Microalbuminuria earliest marker

Diabetic Nephropathy

 

  

Leading cause of increased morbidity and mortality in diabetes Preceded by microalbuminuria Correlated with long-term metabolic control Long diabetes duration Elevated arterial blood pressure Genetic susceptibility

Diabetic nephropathy
Annual screening:

after 5 years’ diabetes duration in pre-pubertal children after 2 years’ diabetes duration in adolescents

Microalbuminuria treatment:
   

improved long-term metabolic control normalising arterial blood pressure smoking discouraged ACE-inhibition/ ARBs

Neuropathy
I. Progressive distal sensori-motor loss

(glove and stocking)

a) Sensory b) Motor

Neuropathy
II. Mono-neuropathies

any nerve: esp. III, IV, VII, peroneal (foot drop) carpal tunnel syndrome

III. Compression neuropathies

IV. Radiculopathies V. Autonomic neuropathies

cardiovascular: postural drop / sudden death intestinal: gastric stasis / nocturnal

Diabetic Neuropathy

Annual screening:

from puberty

Screening method:
ankle reflexes  sensation (temperature discrimination)  non-invasive test of nerve function (biothesiometry)

Neuropathy treatment:

Macro vascular
  

Coronary Artery Disease Peripheral Vascular Disease Cerebrovascular Disease

Accelerated atherosclerosis

Complications: Macrovascular

Strokes / Coronary artery disease / Peripheral vascular disease

The diabetic foot

  

structural deformity (cheiroarthropathy)  abnormal pressures analgesia (repeated minor trauma) ischaemia Ulceration  soft tissue infection  osteomyelitis ± gangrene  amputations

Neuropathic heel ulcer

Diabetic feet

Ischaemic ulcer and gangrene

Toe deformity and ulcer

Charcot foot + ‘rocker’ ulcer

Prevention & Rx
 

Diabetes patients are at high risk Preventive measures generally have a greater absolute effect Lipid lowering therapy
  

Use lower thresholds Treat LDL (statins) and high Trigs / low HDL-chol (fibrates)

 

Aspirin in all pts > 35 yrs Beta-blockade, ACE inhibitors post MI

Treatment of hypertension

Lowering BP reduces nephropathy and retinopathy Lowering BP reduces cardiovascular deaths, strokes, and heart failure (by 30-40%) ACE inhibition has additional benefits
 

in nephropathy possibly in cardiovascular disease

Other Complications

    

Gastrointestinal (gastroparesis, diarrhea) Genitourinary Dermatologic Infectious Cataract Glaucoma

Travelling
Appointment in the out-patient clinic 4–6 weeks before travel  Improve metabolic control, if necessary  Make sure that the family is capable of treating hypo- and hyperglycaemic episodes

Travelling

Long flights:
stick to the ‘home-time’ and normal routines  6-hourly injections of short-acting insulin

REGULAR MONITORING
     

Weight BP Foot examinations Pulse rate Sores, calluses Test for sensations

REGULAR MONITORING

 

Annual eye exams by ophthalmologist Hemoglobin A1 C every 3 to 6 months Annual fasting lipid panels Urine test for presence of proteins

Always Refer in c/o
ketoacidosis  severe dehydration  very young age  Uncontrolled DM  infection  psychosocial problems

CME
On ECG & Blood Pressure: Practical Tips for Family Physicians At Blue Waters Andheri Link Road On 16th Feb 9.30pm onwards Followed by Cocktails & Dinner

Sign up to vote on this title
UsefulNot useful