Diabetes
-Definition
Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from:
- Defects in insulin secretion
- Insulin action
- Or both
Diabetes
-Stats
Type II DM = 95% of cases
Type I DM = 5 %
- Cardiovascular disease is the MOST prevalent cause of mortality and morbidity in diabetic populations
- Diabetic and hypertensive nephropathy are MOST common cause of END STAGE RENAL DZ
- Increased risk of non-traumatic lower limb amputations
Diabetes
-Diabetic Retinopathy
Most common form of diabetic eye disease
-Leading cause of blindness in adults age 20 - 74 yrs old
Diabetes
-Amputation States
Diabetes is the most common cause of Non-traumatic lower limb amputations
-Non healing wounds and ulcers most common cause of amputation
Diabetes
-Prevalence by Race and Ethnicity
- American Indian 14.7%
- Hispanic 12.5%
- Black, non-Hispanic 11.7%
- Asian 9.2%
- White 7.5%
Diabetes
-By Educational Level
- Less than high school education = 13.3%
- High school = 9.7%
- More than high school 7.5%
Social determinants of health is VERY important with Diabetes
Diabetes
-“Terrible Triumvirate”
- Impaired insulin secretion by pancreas
- Decreased peripheral glucose uptake by skeletal muscles
- Increased hepatic glucose production
Diabetes
-Ominus Octet **
- Increased glucagon secretion secretion
- Increased glucose reabsorption by the kidneys
- Increased lipolysis
- Decreased incretin effect
- Neurotransmitter function in the brain
+ “Terrible Triumvirate” - Decreased insulin secretion
- Glucagon secretion
- Increase hepatic glucose secretion
Diabetes
-4 categories
- Type 1 DM
- Type 2 DM
- Gestational DM
- Diabetes from secondary causes
- medications (glucocorticoids, thiazides diuretics, atypical antipsychotics
- DZ of the pancreas (Pancreatitis, pancreatic cancer, cystic fibrosis)
- Hormonal syndromes (Pneochromocytoma)
Diabetes
-Gestational DM
- Occurs in pregnant women who were not previously diabetic
- 10% of pregnancies in US
Diabetes from Secondary causes
-Medications
- Glucocorticoids
- Thiazides diuretics
- Atypical antipsychotics
Diabetes from Secondary causes
-Diseases of the Pancreas
DZ destroy pancreatic beta cells include:
- Chronic Pancreatitis
- Polycystic Ovarian Syndrome
- Cushing’s syndrome
- Hemochromatosis
Diabetes from Secondary causes
-Hormonal Syndromes
- Pheochromocytoma
2. Type I and Type II DM
Type 1 Diabetes
-How it happens
- Juvenile-Onset Diabetes (Insulin-dependent diabetes)
- Need exogenous Insulin for survival
-In genetically predisposed person, there is Autoimmune destruction of beta cells w/in the Islets of Langerhans
-Destroyed pancreas can no longer transport glucose into the cells
—Excess glucose in blood leads to hyperglycemia
Type I Diabetes
-Education on management
This is a chronic condition that requires life-long management
-It is manageable with Insulin
Type-1 Diabetes
-Pathogenesis process
- Genetic or Environmental (Viral Infection)
- Autoimmune insulitis w/ antibodies against Memory T cells specific for Insulin
- Beta cell destruction
- Severe Insulin Deficiency
- Type 1 Diabetes
Type 1 Diabetes
-Clinical Presentation
- Abrupt onset
- 3 P’s (polyuria, polydipsia, polyphagia)
- Weight loss
- blurred vision
- Fatigue
- Abdominal pain N/V
- Hyperventilation
8 Dry skin/ slow wound healing
Usually present in the ER not primary care
Type-1 Diabetes
-Physical Exam (PAD symptoms)
Make sure to screen for peripheral artery disease in diabetics
-This will typically be reported as “leg pain when walking”
Type-1 Diabetes
-Diagnostic Testing
- Serum Glucose
- HbA1C
—both of these exams are usually very high
C-peptide level can be helpful in differentiating between type 1 and type 2 diabetes
Diagnostic criteria for acute onset Type 1 DM
- Occurrence of DKA <3 months after onset of hyperglycemia symptoms (3 p’s)
- Need for continuous insulin therapy after diagnosis of DM
- Positive test result of anti-islet antibodies
- Presence of endogenous insulin deficiency w/out verifiable anti-islet antibodies
- *Acute-Onset Type-1 DM: (Autoimmune) fulfilled criteria 1, 2, and
- *Acute-Onset Type 1 DM: fulfilled criteria 1, 2, and 4
Diagnostic Tests That Help Distinguish Type 1 and Type 2 DM
- C-peptide level
- GAD-65 autoantibodies
- Insulin autoantibodies
- Islet cell autoantibodies
These tests are NOT usually done in primary care. Allow endocrinologist to manage testing
Type-1 Diabetes
-Differential Diagnosis List
- Hyperparathyroidism (Over production of hormone that regulates calcium and phosphate)
- Diabetes insipidus (Increased Urine d/t decreased ADH production, or kidneys cannot respond to ADH)
- Cushing’s syndrome (Increased adrenocortical secretion of cortisol.. Moon face, striae)
- Pheochromocytoma (Adrenal gland tumor of chromaffin cells)
- Acromegaly (excessive enlargement of limbs d/t increased pituitary growth hormone)
- Hyperaldosteronism (overproduction of aldosterone that controls Na and K)
- Pancreatitis
- Infection
- Medication
Type-1 Diabetes
-Pharmacotherapy
Insulin therapy varies from patient to patient
-Hypoglycemia is the MOST serious side effect
Consider factors such as:
-Exercise, activity, meal consumption, mealtimes, sleep pattern, illness and psychological wellbeing in ADJUSTING INSULIN DOSE.
Affordability is also part of consideration
Type-1 Diabetes
-Insulin Therapy
Basal (Long-acting) (Can use multiple injections of insulin pumps)
-Insulin Glargine
Bolus (rapid acting)
-Insulin Lispro
Basal (Long-acting) insulin is insufficient to manage diabetes alone. Needs rapid acting as well.
