Diabetes MellitusFifth Stage-Medicine

Dr. Sarbast Fakhradin

MBChB, MSc Diabetes Care & Management

CLINICAL EXAMINATION OF THE PATIENT WITH DIABETES

Pathophysiological basis of the symptoms and signs of uncontrolled diabetes mellitus.

Symptoms of hyperglycaemia:• Thirst, dry mouth • Polyuria • Nocturia • Tiredness, fatigue, lethargy • Noticeable change in weight (usually weight loss) • Blurring of vision • Pruritus vulvae, balanitis, genital candidiasis (Infection)• Nausea; headache • Hyperphagia; predilection for sweet foods • Mood change, irritability, difficulty in concentrating, apathy• Type 2 diabetes may have an insidious onset of hyperglycemia and may

be relatively asymptomatic initially particularly in obese patient.

Differences between type1 &2:

Overlap may occur between the types•

Type1 Type2

Age of onset <40 years >50 years

Duration of symptoms Weeks Months-years

Body weight Normal or low Obese

Ketonuria Yes No

Autoantibody &other autoimmune disease

Yes No

Diabetic complication at diagnosis No Yes 10-20%

Family history of diabetes uncommon common

Acute complication Ketoacidosis Hyperosmolar nonketotic coma

• Latent Autoimmune Diabetes in Adults (LADA) is a form of autoimmune (type 1) which is diagnosed in individuals who are older than the usual age of onset of type 1 diabetes. Often, patients with LADA are mistakenly thought to have type 2 diabetes, based on their age at the time of diagnosis.

MODY – Maturity Onset Diabetes of the Young: is a monogenic form of diabetes with an autosomal dominant mode of inheritance, Different subtypes of MODY are identified based on the mutated gene. It can occur at any age and family history of diabetes is not always obvious.

•

Metabolic Syndrome (Syndrome X)• It’s a coexistence of a cluster of conditions, all of which

predispose to cardiovascular disease. Insulin resistance is the primary defect and the presence of obesity is a powerful amplifier of the insulin resistance.

• Features of the metabolic syndrome• Hyperinsulinaemia

• Type 2 diabetes or impaired glucose tolerance

• Hypertension

• Low HDL cholesterol & elevated triglycerides

• Central (visceral) obesity

• Microalbuminuria

• Increased fibrinogen

• Increased plasminogen activator inhibitor-1

• Increased C-reactive protein (CRP)

• Elevated plasma uric acid

Investigation1. Urine testing

• (Glycosuria)Best to do it 1-2hours after main meal which select much milder cases than fasting urine. Disadvantage is individual variation in renal threshold for glucose.

Differential diagnosis of glycosuria:1. DM

2. Non diabetic glycosuria due to glucose.

Glucose appeared in urine despite normal blood glucose e.g. Fanconi’s syndrome, dysfunction of the proximal renal tubules, chronic renal failure, pregnancy(common to have glyosuria by ↑GFR during pregnancy&↑glucose load 50% of pregnant has sugar in urine specially after the 1st trimester & in the last weeks lactose may be present).

3. Non diabetic glycosuria due to sugars other than glucose, lactosuria during late pregnancy & lactation is most common.

4. Alimentary glycosuria (lag storage).

Normal or after gastric surgery or hyperthyroidism or hepatic disease, this is benign &not related to diabetes.

 

•  Ketonuria: Conditions leads to ketonuria apart from DKA are starvation, high fat diet,

alcoholic ketoacidosis, fever, exercising strenuously for long periods, & repeated vomiting.

• Protein: Standard dipstick testing for albumin detects urinary albumin at concentrations

> 300 mg/day. but smaller amounts (microalbuminuria: 30-299 mg/day) can only be measured using specific albumin dipsticks or by quantitative biochemical laboratory measurement

• 2. Blood glucose levels:• Laboratory glucose testing in blood relies upon an enzymatic

reaction (glucose oxidase) and is cheap, usually automated and highly reliable. Glucose concentrations are lower in venous than in arterial or capillary (fingerprick) blood.

• Whole blood glucose concentrations are lower (10-15%) than plasma concentrations because red blood cells contain relatively little glucose. In general, venous plasma values are the most reliable for diagnostic purposes.

• 3. Glycated hemoglobin (HbA1c):• It is a slow non-enzymatic covalent attachment of glucose to

haemoglobin (glycation) increases the amount in the HbA1 (HbA1c) fraction relative to nonglycated adult haemoglobin (HbA0). Glycated haemoglobin provides an accurate and objective measure of glycaemic control over a period of weeks to months.

• The rate of formation of HbA1c is directly proportional to the ambient blood glucose concentration; a rise of 1% in HbA1c corresponds to an approximate average increase of 2 mmol/L (36 mg/dL) in blood glucose.

• HbA1c concentration reflects the integrated blood glucose control over the lifespan of the erythrocyte (60-120 days). The recommended target HbA1c is 7% or less, to minimise the risk of vascular complications.

Diagnosis

• Patient complains of symptoms suggesting diabetes + one abnormal blood glucose.

• In asymptomatic patients two samples are required to confirm diabetes.

• When a diagnosis of diabetes is confirmed, other investigations should include plasma urea, creatinine and electrolytes, lipids, liver and thyroid function tests, and urine testing for ketones, protein or microalbuminuria.

• The diagnostic criteria for diabetes in pregnancy are more stringent than those recommended for non-pregnant subjects. Pregnant women with abnormal glucose tolerance should be referred urgently to a specialist unit for full evaluation.

• Stress Hyperglycemia:• In some people, an abnormal blood glucose result is

observed under conditions which impose a burden on the pancreatic β cells, e.g. during pregnancy, infection, myocardial infarction or other severe stress, or during treatment with diabetogenic drugs such as corticosteroids. It usually disappears after the acute illness has resolved. However, blood glucose should be remeasured and an OGTT will often show persistence of impaired glucose tolerance.

Oral Glucose Tolerance Test•  Indications:

1. IFG

2. IGT

• How to perform an 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

• Plasma glucose is measured before and 2 hrs after a 75 g oral glucose drink

Management• 1. Education

• 2. Lifestyle modification alone (50%)

• 3. Lifestyle modification + Oral antihyperglycemic (20-30%)

• 4. Lifestyle modification + Insulin (20-30%)

• 5. Lifestyle modification + Oral agents + Insulin

New/Future treatments – Type 1 DM

• Insulin pump

• Stem cells research: Bone marrow, cord blood, panceatic, embryonic.

• BCG

• Islet transplantation.

Comprehensive diabetes care of type 2 DM

Thank you Question?