Diabetes Mellitus PDF

Fourth Year, 1st Semester, 2024-2025  DIABETIC KETOACIDOSIS Diabetic ketoacidosis is true emergency. In patients with type 1 diabetes, ketoacidosis is usually precipitated by the patient omitting insulin, or an acute illness. Infection is a common cause of DKA and should be thoro...

Fourth Year, 1st Semester, 2024-2025  DIABETIC KETOACIDOSIS Diabetic ketoacidosis is true emergency. In patients with type 1 diabetes, ketoacidosis is usually precipitated by the patient omitting insulin, or an acute illness. Infection is a common cause of DKA and should be thoroughly explored. Patients with DKA may be alert, stuporous, or comatose at presentation. The hallmark diagnostic laboratory values for DKA include hyperglycemia, anion gap acidosis, and large ketonemia or ketonuria. Clinical features: DKA usually evolves rapidly over a 24-hour period. Common, early signs of ketoacidosis include nausea, vomiting, abdominal pain, and hyperventilation. The earliest symptoms of marked hyperglycemia are polyuria, polydipsia, and weight loss. As hyperglycemia worsens, neurologic symptoms appear and may progress to include lethargy, seizure, and coma. Common causes of DKA include: infection; noncompliance, inappropriate adjustment, or cessation of insulin; new-onset diabetes mellitus; and myocardial ischemia. Patients with DKA have fluid deficits of several liters as well as significant sodium and potassium deficits.  Cornerstones of therapy:  Restoration of intravascular volume with normal saline,  followed by hypotonic saline to replace free water,  potassium supplements, and  insulin given by continuous IV infusion to restore the patient’s metabolic status.  TREATMENT OF COMPLICATIONS Nephropathy Hypertension Coronary Heart Disease Dyslipidemia Nephropathy Glucose and BP control are important for preventing and slowing progression of nephropathy. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have shown efficacy in preventing the progression of renal disease in patients with diabetes. Coronary Heart Disease Multiple risk factor intervention (treatment of dyslipidemia and hypertension, smoking cessation, and antiplatelet therapy) reduces macrovascular events. Aspirin (75 to 162 mg daily) is recommended in all patients with established CVD. Clopidogrel may be used in patients allergic to aspirin. Dyslipidemia Statin therapy is recommended regardless of baseline lipid levels in patients with overt CVD or without CVD who are over the age of 40 or have CVD risk factors other than diabetes. Hypertension The ADA recommends a goal BP less than 130/80 mm Hg in patients with DM. ACE inhibitors and ARBs are recommended for initial therapy. Many patients require multiple agents (three on average), so diuretics and calcium channel blockers are useful as second and third agents. EVALUATION OF THERAPEUTIC OUTCOMES To follow long-term glycemic control for the previous 3 months, measure A1C at least twice a year in patients meeting treatment goals on a stable therapeutic regimen. At each visit, ask patients with type 1 DM about the frequency and severity of hypoglycemia. Document any hypoglycemic episodes requiring assistance of another person, medical attention, or hospitalization and take steps to prevent future episodes.  Screen for complications at the time of diagnosis and thereafter as follows: ✓ Obtain yearly dilated eye exams in type 2 DM and an initial exam in the first 5 years in type 1 DM, then yearly. ✓ Assess BP at each visit. ✓ Examine the feet at each visit, including palpation of distal pulses and visual inspection for skin integrity, calluses, and deformities. ✓ Screen for pedal sensory loss annually using a 10-g force monofilament. ✓ Screen for nephropathy with urine microalbumin at the time of diagnosis in patients with type 2 DM and 5 years after diagnosis in type 1 DM. At least once a year, assess urinary albumin (urine albumin-to- creatinine ratio) and eGFR in all patients with type 2 DM and in patients with type 1 DM for at least 5 years. ✓ Check fasting lipid panel annually if the patient is on lipid-lowering therapy.