Transcript DM-1-fianl - howMed Lectures
Diabetes Mellitus
Global and national prevalence of diabetes Types of diabetes Pathogenesis of diabetes Classification and criteria for lab diagnosis of diabetes Lab investigations for a patient of diabetes MCQ’s
The Miracle of Insulin
Patient J.L., December 15, 1922 February 15, 1923
Diabetes Mellitus
“Diabetes is a dreadful affliction,---------”.
Areteus of Cappadosia in 2 nd Century.
It continues to be a sinister disease, if not taken care of.
Sheikh M.Z, Diabetes Mellitus: The Continuing Challenge, JCPSP 2004 Vol.14(2), 63-64
Diabetes a
global
epidemic
Years 1998 2003 Diabetics (Million) 135 170 2025 Sheikh M.Z, Diabetes Mellitus: The Continuing Challenge, JCPSP 2004 Vol.14(2), 63-64 300
WHO Estimates
WHO ranks Pakistan 7 th on diabetes prevalance list (The Nation ; English Daily- 15 th Nov 2008) Pakistan ranked
eighth
in the world for Diabetes Mellitus (1995), After India, China, USA, Russia, Japan, Brazil, and Indonesia.
Asian and other developing countries have higher prevalence of diabetes mellitus as compared to
Western
population Sheikh M.Z, Diabetes Mellitus: The Continuing Challenge, JCPSP Vol.14(2) 63-64 ,
Diabetes epidemiology in Pakistan
Years 1995 Diabetics (Million) 4.3
2025 14.5
Sheikh M.Z, Diabetes Mellitus: The Continuing Challenge, JCPSP 2004 Vol.14(2) 63-64
The provincial prevalence of diabetes mellitus- Pakistan
Province
Balochistan
Diabetes
8.4% Kyber Pakhtun Khwa (KPK) Sindh 11.1% 13.9% Punjab* 10.9
Basit .A et al, Frequency of Chronic Complications of type II Diabetes JCPSP 2004 Vol.14 (2): 79-83 *Shera AS et a; Pak national diabetes survey, J of Primary Care Diab, 2010 Vol 4 79-83
Gender
prevalence of DM
Diabetes Mellitus
Males 16.2% Females 11.7%
Impaired Glucose Tolerance
Males
Females
8.2%
14.3%
Sheikh M.Z, Diabetes Mellitus: The Continuing Challenge, JCPSP 2004 Vol.14(2) 63-64
SURGE
IN DIABETES MELLITUS
Developing countries > 200%
Developed countries > 45% Type 2 diabetes, will be 90% of all cases .
Sheikh M.Z, Diabetes Mellitus: The Continuing Challenge, JCPSP 2004 Vol.14(2) 63-64
Normal Pancreatic Islets:
ß cells Glucagon cells
Insulin Promotes Anabolism
Insulin lowers plasma glucose by: 1.
2.
3.
4.
Increasing glucose transport into most insulin sensitive cells Enhancing cellular utilization and storage of glucose Enhancing utilization of amino acids Promoting fat synthesis
INSULIN
Glucagon Is Dominant In The Fasting State
Glucagon prevents
Glucagon is secreted when plasma glucose levels fall below 100 mg/dL.
The liver hypoglycemia .
is the primary target of glucagon.
Glucagon stimulates glycogeno lysis gluco neo genesis and to increase glucose output by the liver.
Glucagon release is also stimulated by plasma amino acids .
GLUCAGON
Pathogenesis of Type 1DM
Genetic HLA-DR3/DR4 Environment ?
Viral infe..??
Autoimmune Insulinitis ß cell Destruction Severe Insulin deficiency Type 1 DM
Natural History Of “Pre”–Type 1 Diabetes
Putative trigger
-Cell mass 100% Genetic predisposition Cellular autoimmunity Circulating autoantibodies (ICA, GAD65) Insulitis
-Cell injury Loss of first-phase insulin response (IVGTT) Glucose intolerance (OGTT) Clinical onset — only 10% of
-cells remain “Pre” diabetes Diabetes Time Eisenbarth GS. N Engl J Med. 1986;314:1360-1368
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Type 1 DM
Insulinitis
Pathogenesis of Type 2 DM
ß cell defect Genetic Environment Obesity ???
Abnormal Secretion Insulin resistance
Relative Insulin Def.
ß cell exhaustion Type 2 DM IDDM
Is It Gluttony or Sloth??
Jack in the Box
Bacon Ultimate Cheeseburger
1020 Calories 71 grams of Fat Average American child or teen watches 3-4 hours TV per day
H4046
Subcutaneous Fat Gluteal Fat Viceral Fat
Islets in Type 2 Diabetes:
Loss of ß cells
Amyloid deposits
Hyalinization
Natural History of Type 2 Diabetes
Impaired glucose tolerance Undiagnosed diabetes Known diabetes Insulin resistance Insulin secretion Postprandial glucose Fasting glucose Microvascular complications Macrovascular complications Adapted from Ramlo-Halsted BA, Edelman SV. Prim Care. 1999;26:771-789
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Type-1
Age : < 40 Years Duration : Weeks Ketonuria : Common Insulin Dependent Autoantibody : Yes Family History : No Insulin levels : very low Islets : Insulinitis Complications : Acute & Metabolic
Type-2
> 40 Years Months to years Rare Independent * No Yes Normal or high * Normal / Exhaustion Complications Late and vascular.
I. CLASSIFICATION AND DIAGNOSIS OF DIABETES
Classification of Diabetes
Type 1 diabetes
β-cell destruction
Type 2 diabetes
Progressive insulin secreting defect
Other specific types of diabetes
Genetic defects in β-cell function, insulin action Diseases of the exocrine pancreas Drug- or chemical-induced
Gestational diabetes mellitus
ADA. I. Classification and Diagnosis.
Diabetes Care
2011;34(suppl 1):S12.
Criteria for the Diagnosis of Diabetes
HbA1C ≥6.5%
OR
Fasting plasma glucose (FPG)
≥126 mg/dl (7.0 mmol/l)
OR
Two-hour plasma glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT
OR
A random plasma glucose ≥200 mg/dl (11.1 mmol/l) ADA. I. Classification and Diagnosis.
Diabetes Care
2011;34(suppl 1):S13. Table 2.
Prediabetes: IFG, IGT, Increased A1C Categories of increased risk for diabetes (Prediabetes)* FPG 100-125 mg/dl (5.6-6.9 mmol/l): IFG or 2-h plasma glucose in the 75-g OGTT 140-199 mg/dl (7.8-11.0 mmol/l): IGT or A1C 5.7-6.4% *For all three tests, risk is continuous, extending below the lower limit of a range and becoming disproportionately greater at higher ends of the range.
ADA. I. Classification and Diagnosis.
Diabetes Care
2011;34(suppl 1):S13. Table 3.
Recommendations: Detection and Diagnosis of GDM
Screening
use plasma glucose fasting and 2 hours after breakfast, if abnormal go for 50 gram oral glucose challenge test.
In pregnant women previously known to have diabetes, and screening test abnormal go for
gram glucose- OGTT confirmatory test for diagnosis of GDM at 24-28 weeks gestation, using a 100
Other investigations:
•
Serum Urea.
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Serum Creatinine
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Serum Lipid profile: cholesterol; triglyceride; LDL-C; HDL-C.
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Serum sodium, potassium,
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24 hour urine for: protein; creatinine clearance; microalbumin;
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Spot urine for microalbumin
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Spot urine for albumin creatinine ratio- ACR
Other investigations and evaluations: Blood complete picture
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Urine routine examination: glucose; protein/, albumin, WBC, sp gravity.
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Urine for ketone bodies
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Arterial blood gases ABG’s
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Ultra sound liver- Fatty liver
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Fundoscopy- for diabetic retinopathy;
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Routine eye exam: diabetic cataract
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Blood pressure measurement
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Examination of feet- ulcer; poor sensations/neuropathy