Diabetes Mellitus Tipos 1 y 2

Diabetes Mellitus

• A group of metabolic diseases sharing hyperglycemia due to defects in insulin secretion and/or action.
• There is also an alteration in the metabolism of other energy molecules.

Diabetes Type 1

• Secondary to destruction of pancreatic β cells.
• Absolute insulin deficiency.
• Antibodies present: anti-insulin, anti-glutamate decarboxylase 65, anti-tyrosine phosphatase, anti-pancreatic islet cells, anti-zinc transporter 8.
• Other types include gestational diabetes mellitus (diagnosed in the second or third trimester) and specific types like MODY.

Diabetes Type 2

• Progressive defect in secretion and resistance to insulin.
• Related to obesity, family history, and being of Native American, Hispanic, or Asian descent (60-90% have a family member with DM2).

Epidemiology

• Prevalence in the population is 20-22%, with 90% being DM type 2 and 10% DM type 1.
• Suspect MODY genetic defects (genetic defect of cell B) when diabetes occurs before age 25 with 2 affected generations; MODY 3 is the most frequent and related to the nuclear hepatic factor.

Screening Recommendations

• Screen annually for DM2 with HbA1c in high-risk patients, regardless of age. Risk factors include obesity, hypertension, family history of diabetes, sedentary lifestyle, gestational diabetes, PCOS, SAOS, and metabolic syndrome.
• Asymptomatic individuals without risk factors: screen from age 45, repeating every 3-5 years with available tests: HbA1c, fasting glucose, or glucose tolerance test.
• Screen all obese patients for DM.
• Asymptomatic patients without risk factors: start screening at age 45.
• Patients with elevated cardiovascular risk: consider an exercise stress test.
• Use the FINDRISC questionnaire as a screening tool.
• Consider plasma glucose with FINDRISC > 12 points.

Diagnosis of Diabetes

• Confirmation of diabetes:
  • Symptoms + 1 altered test.
  • No symptoms + 2 altered tests.
  • Typical symptoms + random glucose > 200 mg/dL.
• Criteria are per ADA 2018.
• Fasting plasma glucose ≥ 126 mg/dL (7.0 mmol/L)—fasting defined as no caloric intake for at least 8 hours.
• 2-hour plasma glucose ≥ 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test with 75 grams of glucose dissolved in water.
• Hemoglobin A1c (A1C) ≥ 6.5% (48 mmol/mol); test to be performed in certified laboratories.
• Patient with classic hyperglycemia symptoms or hyperglycemic crisis and random glucose ≥ 200 mg/dL.
• Initial classic symptoms: polyuria, polydipsia, polyphagia, weight loss.

Diagnostic Considerations

• HbA1c is better for ruling out diabetes, and an oral glucose tolerance test confirms the diagnosis.
• In suspected type 2 diabetes mellitus, conduct a complete physical examination searching for secondary complications like neuropathy, nephropathy, retinopathy, ischemic heart disease, and vascular disease.

Non-Pharmacological Treatment

• Weight loss: > 7% reduction, exercise 150 minutes per week (5 times/week).
• Diet: Saturated fats < 10% of intake, cholesterol < 300 mg/day, sodium < 2.5 g/day in hypertensives, protein < 20% of caloric intake.

Pharmacological Treatment

• Initiate with metformin at 425 mg and lifestyle changes.
• Use ACE inhibitors for hypertension (first choice).
• Initiate Insulin in patients with BMI < 25, young patients, acute complication of DM2, and pregnancy

Subsequent Treatment Adjustments Based on HbA1c Levels

• HbA1c < 7.9%: Maintain monotherapy; consider sitagliptin if metformin is contraindicated.
• HbA1c > 8%: Dual therapy with metformin + DPP-4 inhibitor (sitagliptin), SGLT-2 inhibitor (dapagliflozin or canagliflozin), or sulfonylurea (glimepiride).
• HbA1c > 9% and asymptomatic: Dual or triple therapy with metformin + DPP-4 inhibitor + glipizide.
• HbA1c > 9% and symptomatic: Initiate metformin + NPH insulin 10 IU or 0.2 IU/kg.
• If glycemic goals are met, cite every 3 months; if not, cite monthly and escalate treatment.

Glycemic Control Goals

• HbA1c < 7.0% (53 mmol/mol)
• Preprandial capillary glucose 80-130 mg/dL
• Postprandial capillary glucose < 180 mg/dL
• Do not initiate combination therapy with SGLT-2 inhibitors in adults recently diagnosed, only use as alternative if DPP-4 not allowed

Treatment Specifics

• Start pharmacologic treatment with metformin and lifestyle changes in newly diagnosed DM2 patients; consider sitagliptin if metformin is contraindicated.
• Consider combination therapy with metformin and another oral antidiabetic in adults newly diagnosed with DM2 and HbA1c > 8%.
• Metformin-sulfonylurea combination (glimepiride or gliclazide) with low hypoglycemia risk could be an alternative, or metformin with an SGLT-2 inhibitor.
• Start basal insulin dose at 10 units daily or 0.2 units/kg. Increase by 2-4 units if fasting glucose is above the target.

Treatment Contraindications

• Do not initiate combination therapy with metformin and thiazolidinediones due to increased risk of fractures, heart failure, bladder cancer, and weight gain.
• Do not initiate therapy with sulfonylureas like glibenclamide due to hypoglycemia risk; consider other medications first.

Goals for Adults, DM type 1, and Pregnant women

• Adults:

  • HbA1C: <7%
  • Preprandial glucose: <130 mg/dl
  • Postprandial glucose: < 180 mg/dl

• DM type 1:

  • HbA1C: < 7.5%
  • Preprandial glucose: 72-126 mg/dl
  • Postprandial glucose: < 180 mg/dl

• Pregnant women:

  • HbA1C: <6%
  • Preprandial glucose: < 95 mg/dl
  • Postprandial glucose: < 140 mg/dl

• There are specific goals for children and older adults.

Diabetic Nephropathy

• Screen at diagnosis and annually.

• Best screening method: Urine albumin-creatinine ratio > 30 mg/dL in 24 hours.

• Screen right at DM2 diagnosis, and annually by albuminuria quantification through urinary albumin/creatinine in 24h or sampling.

Diabetic Retinopathy

• Ophthalmology screening at diagnosis and annually thereafter.
• Later screening is based on severeness of the retinopathy.
  • Those who do not have changes and no alterations in the retina are evaluated every 1 to 2 years.

Diabetic Neuropathy

• Annual monofilament test.
• No peripheral neuropathy: anually
• Peripherical neuropathy: Every 6 months
• Peripheral neuropathy with PAD or other foot deformities: Each 3 to 6 months.
• Peripheral neuropathy and history of Ulcers: Each 1 to 3 months.

Management

• DM2 and hypertension patients have a goal less than 80 mmHg diastolic blood pressure and 130 to 140 mmHg systolic blood pressure; young patients or nephropathy patients target is less than 130 mmHg systolic pressure.
• Lipid profiles at diagnosis and repeating annually if normal. If abnormal, retest every 3 to 6 months according to achievements and medical criteria.

Insulin Types

• Rapid-acting: onset 5-15 minutes, peak 1-2 hours, duration 3-5 hours; inject immediately before meals
• Short-acting: onset 30-60 minutes, peak 2-4 hours, duration 5-8 hours; inject 30 minutes before meals
• Intermediate-acting: onset 2-4 hours, peak 4-8 hours, duration 12-24 hours; inject 30 minutes before meals
• Long-acting: onset 1-2 hours, no peak, duration 24+ hours; inject one or two times a day
• Basal insulins are preferred as they are less likely to cause hypoglycemia.

Additional Considerations

• Insulin should be administered immediately when the decompensated patient has hyperglycemia and or symptoms.

Acute Peptic Acid Disease

• Disorders of the proximal gastrointestinal tract, affecting the proximal portion of the duodenum and the stomach.
• Ulcer: Damage to the gastric or duodenal wall that penetrates (>5mm) beyond the muscularis mucosae.

Epidemiology

• 80-90% of patients heal with medication and lifestyle changes, but 60% recur without treatment.
• 25% of peptic ulcers have a complication.

Etiology

• Helicobacter pylori: Gram-negative bacillus, urease positive which transforms ammonia and CO2.
• CagA Strain: Suggestive of atrophic gastritis and is a precursor to gastric cancer.
• Risk factors: H. pylori infection, chronic NSAID use, age over 65, alcohol, tobacco, anxiety, AAS at low doses and previous ulcer.
• Two major etiologic factors for ulcerative disease: AINE, H. Pylori.

Peptic Ulcer

• Usually located at the duodenum.
• It is more frequent with 95% relationship with H. Pylori.
• Epigastric pain appearing 1.5 to 3 hours after a meal and is relieved by consuming food or antacids.

Gastric Ulcer

• Located in the lesser curvature.
• Less frequent, occurring in 70-80% ratio to H. pylori.
• Epigastric pain increases in intensity with food intake and can produce vomiting due to gastric obstruction.

Biopsy

• A biopsy at the endoscopy and one control must be taken after ending treatment.

Diagnosis of Peptic Acid Disease

• Under the age of 55 a urea breath test must be done as a non-invasive method

• Golden Standard: an endoscopy where we take a biopsy; can take up to 10 days to return.

• Serology tests: Are done when we suspect false negatives.

Management of Peptic Acid Disease:

1. First Line: Clarithromycin c/12hrs 500mg + Amoxicillin 1 gr c/12 hrs + Omeprazole 20mg c/12 hrs for 14 days.
2. Second Line: Tetracycline 500mg c/6hrs + Bismuth 525mg + Tinidazole 1gr c/12 hrs + Omeprazole 20mg c/12 hrs for 14 days.
3. Third Line: Azithromycin 500mg c/24 hrs + Furazolidone 200mg c/8 hrs + Omeprazole 20mg c/12 hrs for 10 days.

Under 55 years of age

• If there are high dyspepsia symptoms, is there is no response to Tx, Alarm signs are present; an endoscopy must be done. If is positive, treat. If negative; SEGD or Urea Test must be done and is positive after treatment.

• Anemia, Blood vomit, melena or blood stools signs bleeding; Vomit points to obstruction. Anorexia suggests cancer..

• Follow-up: Urea test is considered a test of election; after 4 weeks after following Tx. In an Ulcer Biopsy a control biopsy to verify at the end.

• Main Complications: Hemorrage and perforation.

Acute Diarrhea in Adults

• Increased liquid, volume, frequency or depositions and fewer of 14 days (<14 days persistente).

• In between the more important patogens of the Acute Diarrhea are found Rotavirus, Escherichia Coli. Salmonella sp, Shigella, Vibrión Choleare, Giarda lambia and Entamoeba histolytica.

Etiology

• Infections Virus most communy. Bacterias, Parasites and Fungi.
• Main Risks: Water and contaminate Food. Deficiencies and traveling endemic places.

1. It is presente > 3 bowel movements in 24 hrs + enteric symptom: (nausea, vomiting pains; colic abdominal, urgency).

2. Its use is reservated in patients that there is no Blood.

• Test Initial : Type and duration.

• Gold standard: Coprocultivo is requested in selected cases.

• Diagnostics: used in disentry. For those thast are Moderate to severs and allows to have a directed Specific test.

• Grade of Deshydration

  • Level Grade : Hidratation.

  • Grave: Hidratation.

• SRO Level is recomendated in dehidration.

Otitis Media Aguda

• It mainly affects Childeren

Epidemiology

• 50% happens in chilerdern
• OMD id the most often cause of damage the audicion
• In 13 to 21% is present Factors that put you at risk are age, genetics and the environment

Clinnica

• Acute pain in the mid side
• When inspecting it sees a red ear dur to inflamtion The otoscope method is used for more accurate explorations.

Complications

• Mastoiditis
• Damage to the facial nerve.