DM Presentation PDF

Diabetes mellitus 01/28/2025 1  By the end of this lesson student will be able to  Define Diabetes mellitus  Epidemiology and GLOBAL Considerations  Differentiate between its types  Understanding the pathophysiology of diabetes  Identify the cause,risk...

Diabetes mellitus 01/28/2025 1  By the end of this lesson student will be able to  Define Diabetes mellitus  Epidemiology and GLOBAL Considerations  Differentiate between its types  Understanding the pathophysiology of diabetes  Identify the cause,risk factors,sign and symptoms  Explore diagnostic criteria and management strategies  Learn about complications and preventions strategies 01/28/2025 2  INTRODUCTION TO DIABETES Definition Diabetes mellitus is a group of metabolic disorders characterized by the presence of hyperglycemia in the absence of treatment. The heterogeneous etiopathology includes defects in insulin secretion, insulin action, or both 01/28/2025 3  The long-term specific complications of diabetes include  retinopathy,  nephropathy, and  neuropathy.  People with diabetes are also at increased risk of other diseases, including  cardiac,  peripheral arterial and  cerebrovascular disease, cataracts, erectile dysfunction, and  Non alcoholic fatty liver disease. They are also at an increased risk of some infectious diseases such as  tuberculosis and are likely to experience poorer outcomes. 01/28/2025 4  Depending on the etiology of the DM,factors contributing to hyperglycemia include  reduced insulin secretion,  decreased glucose utilization, and  increased glucose production.  The metabolic dysregulation associated with DM causes secondary pathophysiologic changes in multiple organ systems that impose a tremendous burden on the individual with diabetes and on the health care system. In the United States, DM is the leading cause of end-stage renal disease (ESRD), 01/28/2025 5  Non traumatic lower extremity  amputations, and adult blindness. Persons with diabetes  are at increased risk for cardiovascular disease, which is the main cause of morbidity and mortality in this population. 01/28/2025 6  CLASSIFICATION of Dm  Type 1 Dm  Type 2 Dm  GESTATIONAL DM  OTHER TYPES OF DM 01/28/2025 7  CLASSIFICATION of Dm  DM is classified on the basis of the pathogenic process leading to  hyperglycemia  There are two broad categories of DM, designated as either type 1 or type 2 DM. However, there is increasing recognition of other forms of diabetes in which the molecular pathogenesis is better understood and may be associated with a single gene defec 01/28/2025 8  These alternative forms as well as other “atypical” forms may share features of type 1 and/or type 2 DM. Type  1 DM develops as a result of autoimmunity against the insulin producing beta cells, resulting in insulin deficiency 01/28/2025 9 Type 2 DM is a heterogeneous group of disorders characterized by variable degrees  of insulin resistance, impaired insulin secretion, and increased hepatic glucose production.  Defects in insulin action and/or secretion 01/28/2025 10  give rise to the common of hyperglycemia in type 2 DM and have important therapeutic implications now that pharmacologic  agents are available to target specific metabolic derangements. Both type 1 and type 2 diabetes are preceded by a period of progressive  worsening of glucose homeostasis, followed by the development of  hyperglycemia that exceeds 01/28/2025 11  OTHER TYPES OF DM Other etiologies of DM include specific genetic defects in insulin secretion or action, metabolic abnormalities that impair insulin secretion, mitochondrial abnormalities, and a host of conditions that  impair glucose tolerance. Maturity-onset diabetes of the young (MODY) and monogenic diabetes are subtypes of DM  characterized by autosomal dominant inheritance, early onset of  hyperglycemia (usually 3 litters per day or if not quantified a history of increase in urination frequency with increase in volume of urine),  polydipsia(excessive thirst),  Polyphagia(excessive appetite),  unexplained weight loss or fatigue,  then blood tests for diabetes should be done 01/28/2025 36 Indications for screening for asymptomatic individuals Every 3 years for  All Adults Age ≥ 40 years  Adults with BMI ≥ 25 kg/m2  Hypertension (SBP ≥ 140 or DBP ≥ 90mmHg or on treatment for hypertension)  First degree relative with diabetes  and BMI ≥ 25 kg/m2  History of stroke, ischemic heart disease or peripheral arterial disease 01/28/2025 37  Triglyceride >250mg/dl or HDL cholesterol 4 kg  HIV Patients with history of prediabetes or impaired fasting 01/28/2025 38  Common Symptoms of DM  thirst  frequent urination  blurring of vision  fatigue 01/28/2025 39  Signs of diabetes  unintentional weight loss  signs of acute metabolic deterioration (signs of severe dehydration, respiration, )  vomiting,  altered level of consciousness)  clinical signs of chronic complications (acute coronary disease,  stroke, kidney disease, vision loss, diabetic foot) 01/28/2025 40  DIAGNOSTIC CRITERIA FOR DIABETES MELLITUS 01/28/2025 41  Diagnostic criteria for Gestational Diabetes  Diagnose gestational diabetes when one of the following criteria is met:  Fasting plasma glucose: 92– 125mg/dl, or  1-hour post-load plasma glucose: ≥ 180mg/dl, or  2-hour post-load plasma glucose: 153-198mg/dl 01/28/2025 42  Clinical Criteria for initial management of diabetes  Type 1 DM  onset of disease prior to age 30 years,  lean body habitus,  requirement of insulin as the initial therapy,  propensity to develop ketoacidosis; and  An increased risk of other autoimmune disorders such as  autoimmune thyroid disease, adrenal insufficiency, pernicious anaemia, celiac disease, and vitiligo. 01/28/2025 43  Type 2 DM  Onset of disease after the age of 30 years,  are usually obese (80% are obese, but elderly individuals  may not require insulin therapy initially; and  May have associated conditions such as insulin resistance,  hypertension, cardiovascular disease, dyslipidaemia, or PCOS. 01/28/2025 44  Remember:  Diagnosis requires two abnormal test results from the same sample or in two separate samples  Fasting values for venous and capillary plasma glucose are identical.  FBS 101-125 mg/dl is Impaired Fasting Blood Glucose.  Repeat test in 1 Year.  Advise on Healthy Life-Style counselling 01/28/2025 45  COMPREHENSIVE MEDICAL EVALUATION OF DIABETES  DIABETESA complete medical evaluation should be performed at the initial visit to:  Confirm the diagnosis and classify diabetes.  Evaluate for diabetes complications and potential comorbid conditions.  Review previous treatment and risk factor control in patients with established diabetes.  Begin patient engagement in the formulation of a care management plan.  Develop a plan for continuing care 01/28/2025 46  A follow-up visit should include most components of the initial comprehensive medical evaluation  Ongoing management should be guided by the assessment of overall health status, diabetes complications,  cardiovascular risk,  hypoglycaemia risk, and shared decision-making to set therapeutic goals 01/28/2025 47 Comprehensive diabetes evaluation consists of  Past medical and family history  Current medical history  Behavioral factors (diet, alcohol, tobacco, physical activity, sleep, substance use  Medication use  Social life assessment  Physical Exam (V/s, Wt, Ht, BMI, fundoscopy, CVS, Thyroid, Skin, Comprehensive foot exam  Baseline investigations 01/28/2025 48  Assessment and treatment plan  Setting glycemic targets  Lifestyle modifications  Monitoring and treatment of diabetes  Choosing drugs for diabetes management  Screening and treatment of complications and comorbidities  Indications for referral 01/28/2025 49  Baseline investigations for Type 2 DM  Urine analysis-If proteinuria is detected, repeat after 3 months, if still there refer to specialist or manage as per diabetic nephropathy protocol  Lipid profile, SGOT/SGPT /ALP –(if available) Serum Creatinine –(if available)- If abnormal – refer to internist or nephrologist  N.B – For both Type 1 and Type 2 DM patients, check urine for ketones if blood glucose ≥250 mg/dl 01/28/2025 50 Setting diabetes treatment goals  For most patients with diabetes set a target of FBG – 80-130mg/dl  2 hours post meal less than 180 mg/dl (secondary goal after FBG target is achieved) HgA1c < 7% ( If available) 01/28/2025 51  MANAGEMENT OF DIABETESSee  Lifestyle modifications   Advise on 150 minutes per week of moderate intensity exercise (e.g.-brisk walking, farming) with preferably no more than 2 days passing without exercise.  Dietary advise:  Moderate consumption of complex carbohydrates (like pasta, potatoes etc.),  increased fiber intake,  A diet rich in vegetables and 1-2 servings of fruit per day.  use liquid oils and nuts and avocado o moderate consumption of meat 01/28/2025 52  avoiding simple carbohydrates (like sugar, soft drinks, honey, cakes)  minimizing saturated fat intake (like butter, solid oils),  decrease salt consumptiono Avoid alcohol consumption.  If you drink alcohol, drink moderately- no more than one drink a day if you’re a woman or two drinks a day if you’re a man. 01/28/2025 53 If BMI >25 kg/m2, advise at least 5 % weight loss  Advise on moderating salt and alcohol intake and quitting smoking 01/28/2025 54 Management of Type 2 DM with Oral Agents  Initial treatment:  Metformin does not cause weight gain or hypoglycemia and is the recommended initial treatment for people who do not achieve the desired glycemic control with diet and physical activity  Start 500mg PO at bedtime. Increase the dosage gradually according to the diabetes protocol 01/28/2025 55  A second-generation sulfonylurea like glibenclamide or glimepiride can be used as initial (first-line) treatment  when metformin is contraindicated or not tolerated. Sulfonylureas may cause weight gain and hypoglycemia 01/28/2025 56  Insulin therapy can be considered when there are symptoms of diabetes or  the HbA1c level is greater than 9% or FBS > 300mg/dl  Intensification of treatment when metformin alone fails to control glycaemia:  Consider adding glibenclamide 5mg or glimepiride 2mg 01/28/2025 57  Intensification of treatment when metformin and sulfonylurea fail to control glycaemia:  Refer for insulin treatment or add human insulin to oral medications  Remember:  There is a risk of hypoglycemia with sulfonylurea and insulin use if you delay your mealtime or eat less than usual, or the medicine is too much.  Medications must be supported by healthy eating and regular physical activity.  Quitting smoking and stopping harmful use of alcohol are especially important 01/28/2025 58 Management of Type 2 DM with Insulin  If goal not achieved with lifestyle changes and oral agents:  Stop glibenclamide/glimepiride and add NPH 10 iu bedtime and escalate insulin dose by 2 iu every 3 days by checking FBG  If a dose of >20 iu is needed at bedtime, split into morning and evening dose (2/3rd am and 1/3rd pm).  Continue Metformin with same dose  Monitor for hypoglycemia 01/28/2025 59  Type 1 DM Management Protocol  Patients with Type 1 DM need to be initiated on subcutaneous insulin injections as soon as possible.  The type of insulins used should be a combination of long or intermediate acting insulin and short acting (regular) insulin.  Education on diabetes, insulin, hypoglycemia and chronic complications is essential. Advise on diet and exercise is very important 01/28/2025 60 01/28/2025 61  Monitoring  Once good glycemic control has been attained , Follow patients every 3 months  For those able to afford a glucometer , advise on self-monitoring of blood glucose (SMBG)  For Type 2 DM patients not on insulin SMBG may only be needed when changing diet, physical activity or medications and when HgA1c is abnormal despite a normal FBG if ( HgA1c is available )  to check for post prandial hyperglycemia For patients on insulin, they should measure fasting and post prandial measurements as frequently as possible  If HgA1C test is available, check it 2 -4 x/year  Frequency of follow up may be more frequent if indications are there such as change in dose,  hypoglycemia, recent illness or development of microvascular or macrovascular complications 01/28/2025 62  ACUTE COMPLICATIONS OF DIABETES  Diagnosis  Suspicion based on clinical evaluation. Features vary among patients and may include  polyuria,  polydipsia,  fruity odor, confusion,  confusion  Diabetic Ketoacidosis (DKA)  Hyperglycemia: BG ≥250 mg/dL  Ketonuria >1+≥1+  Glycosuria 01/28/2025 63 Hyperosmolar Hyperglycemic State (HHS)  Severe Hyperglycemia: BG>600 mg/dL Change in Mental status  Moderate to severe dehydration 01/28/2025 64  Initial Management of DKA  Start IV Fluids with 1bag NS in 1 hour  if patient is asymptomatic and urine ketone +1, recheck urine ketone after 1 hr  If urine ketone becomes negative escalate treatment and follow patient frequently as outpatient  If ketone >+1 or if symptomatic, give 1st dose of Regular insulin  0.3 iu/kg Sc immediately along with IV fluids and refer to hospital if at health center  If at Hospital treat with the following protocol 01/28/2025 65  Fluids  If hemodynamically unstable, giveNormal saline 1 L over 30 minutes.  May repeat this until stable.  If stable, administer normal saline 1-2L over 2 hr  Subsequent management based on vital signs, free water deficit and urine output  Replace fluid deficits gradually over 24-48 hrs(Overall 6liters for DKA and 9 liters for HHS)  Change fluids to 5%DNS or 5%DWwhen BG is 50 ml/hr) 01/28/2025 70 01/28/2025 71  Hypoglycemia management Hypoglycemia (abnormally low blood glucose) is a frequent iatrogenic complication in diabetic patients, occurring particularly in patients receiving sulfonylurea or insulin.  It is most frequently defined at plasma glucose of 70 mg/dL 01/28/2025 72 Symptoms of hypoglycaemia  headache  hunger  irritability,  anxiety  paraesthesias  palpitations 01/28/2025 73  Signs of hypoglycaemia  sweating  trembling  difficulty in speaking  confusion  ataxia  stupor  pallor  seizures  coma 01/28/2025 74 If RBG/FBG < 70 mg/dl  Give oral glucose 20g (4 teaspoons of sugar, 4 hard candies, or 50 ml of 40% dextrose PO)  If unable to take orally, give instead glucose 40% 50mL IV over 2-3 minutes.  Repeat random blood glucose after 15-20 minutes 01/28/2025 75 MANAGEMENT OF CHRONIC COMPLICA TIONS OF DIABETES Diabetic nephropathy  Check urine for protein at diagnosis for type 2 DM and starting 5 yrs after diagnosis for type 1 DM  If no proteinuria , continue screening every year  If patient has proteinuria do RFT If RFT abnormal , refer to specialist  If RFT normal repeat urine analysis after 3 months  If proteinuria is persistent start on Enalapril 5 mg/d  Appoint every month and do RFT test on every appointment  If creatinine has increased by more than 30% discontinue enalapril  If not , escalate enalapril by 5 mg each month until 20 mg /d and maintain on that dose  Check RFT every 6 months after that 01/28/2025 76  If proteinuria is persistent start on Enalapril 5 mg/d  Appoint every month and do RFT test on every appointment  If creatinine has increased by more than 30% discontinue enalapril  If not , escalate enalapril by 5 mg each month until 20 mg /d and maintain on that dose  Check RFT every 6 months after that 01/28/2025 77  Diabetic neuropathy  Start screening for neuropathy using the 60 second tool mentioned below when DM is diagnosed.  If negative screening , then continue screening yearly  If abnormal, refer for management to tertiary center  If referral not possible and patient has no urgent referral needs such as  an ulcer or absent pulses or a hot swollen foot indicating Charcot’s arthropathy,  then advise on foot care and evaluate the foot every 3 months 01/28/2025 78  If patient has symptoms of peripheral neuropathy such as numbness and burning sensation in the foot or hands (that aggravate mostly at night) then do  Thyroid Function Test and serum vitamin B12 levels if available  If not possible to do these tests, then start on Amitriptyline 25 mg/d at bedtime  If it doesn’t improve, refer to a tertiary center.  Give diabetes foot care education for all patients with diabetes in groups and separately every visit to the health facility. 01/28/2025 79  REASONS FOR REFERRAL TO HIGHER LEVEL IN DIABETES  Recurrent hypoglycemia despite dose adjustment  Hypoglycemic unawareness  Erectile dysfunction  Need for insulin treatment at health center level  Abnormal renal function test  Abnormal retinal screening result  Complaints of neuropathy  Pregnancy  Complaints of chest pain or dyspnea or abnormal cardiovascular exam  DKA at health center level or slowly resolving DKA in primary hospitals. 01/28/2025 80  Thank you 01/28/2025 81