DIABETES MELLITUSDIABETES MELLITUS

THOMAS MILLIGAN, DOTHOMAS MILLIGAN, DO

OSU-COMOSU-COM

FAMILY MEDICINEFAMILY MEDICINE

IntroductionIntroduction

Types of DMTypes of DM DiagnosisDiagnosis ManagementManagement Follow-upFollow-up ComplicationsComplications

TYPESTYPES

Type 1Type 1 Type 2Type 2

TYPE 1TYPE 1

PathophysiologyPathophysiology DiagnosisDiagnosis ManagementManagement

DIAGNOSISDIAGNOSIS

Random BS of 200 plus symptomsRandom BS of 200 plus symptoms– PolyuriaPolyuria– PolydipsiaPolydipsia– Unexplained weight lossUnexplained weight loss

Fasting BS 126 or GreaterFasting BS 126 or Greater– NPO at Least 8 HoursNPO at Least 8 Hours

BS of 200, 2 Hours After 75g Glucose BS of 200, 2 Hours After 75g Glucose ChallengeChallenge

MANAGEMENTMANAGEMENT

Diet Diet – Decrease GlucoseDecrease Glucose– Pt Pt MustMust Not Skip Meals Not Skip Meals

ExerciseExercise InsulinInsulin

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Immune related destruction of Immune related destruction of insulin producing cellsinsulin producing cells

Loss of insulinLoss of insulin Insulin required to prevent DKAInsulin required to prevent DKA

INSULININSULIN

Begin with 20 - 40 u dayBegin with 20 - 40 u day– 2/3 am, 1/3 pm2/3 am, 1/3 pm– Am 2/3 inter, 1/3 regularAm 2/3 inter, 1/3 regular– Pm 1/2 inter, 1/2 regularPm 1/2 inter, 1/2 regular

TimingTiming– Must be given with respect to mealsMust be given with respect to meals

INSULININSULIN

AdjustmentsAdjustments– Average of 35 - 50 u dayAverage of 35 - 50 u day

0.6 - 1.2 u/kg/day0.6 - 1.2 u/kg/day

– Maintain FSBS 100 - 250Maintain FSBS 100 - 250– Pt keeps log of FSBS to avoid Pt keeps log of FSBS to avoid

hypoglycemiahypoglycemia Intermediate insulinIntermediate insulin

– Change evening dose firstChange evening dose first– Beware of nocturnal hypoglycemiaBeware of nocturnal hypoglycemia

INSULININSULIN

Regular insulinRegular insulin– Guided by pre-prandial FSBSGuided by pre-prandial FSBS– Avoid regular insulin at bedtimeAvoid regular insulin at bedtime– More diet and activity sensitiveMore diet and activity sensitive

Multiple Daily Injections (MDI)Multiple Daily Injections (MDI)– Better controlBetter control– Very compliant ptsVery compliant pts

INSULININSULIN

ONSETONSET PEAKPEAK DURDUR – LISPRO 15 - 30 m 1 - 3 h 3 - 6 hLISPRO 15 - 30 m 1 - 3 h 3 - 6 h– REGULAR 15 - 60 m 2 - 6 h 4 - 12 hREGULAR 15 - 60 m 2 - 6 h 4 - 12 h– NPH 1.5 - 4 h 6 - 16 h 14 -NPH 1.5 - 4 h 6 - 16 h 14 -

28 h28 h– LENTE 1 - 4 h 6 - 16 h 14 -28 LENTE 1 - 4 h 6 - 16 h 14 -28

hh

TYPE 2TYPE 2

PathophysiologyPathophysiology DiagnosisDiagnosis ManagementManagement

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Usually after age 30Usually after age 30 Usually obeseUsually obese Insulin resistanceInsulin resistance Insulin may be used, but not Insulin may be used, but not

essentialessential Non ketotic hyperosmolar Non ketotic hyperosmolar

syndrome, not DKAsyndrome, not DKA

DIAGNOSISDIAGNOSIS

Random bs of 200 plus symptomsRandom bs of 200 plus symptoms– PolyuriaPolyuria– PolydipsiaPolydipsia– Unexplained weight lossUnexplained weight loss

Fasting BS 126 or greaterFasting BS 126 or greater– NPO at least 8 hoursNPO at least 8 hours

BS of 200, 2 hours after 75g BS of 200, 2 hours after 75g challengechallenge

MANAGEMENTMANAGEMENT

DietDiet ExerciseExercise Oral agentsOral agents CombinationCombination InsulinInsulin

ORAL AGENTSORAL AGENTS

SulfonylureasSulfonylureas MetforminMetformin TroglitazoneTroglitazone AcarboseAcarbose

SULFONYLUREASSULFONYLUREAS

Diabinese, glucotrol, diabeta, Diabinese, glucotrol, diabeta, micronase, prandin, amarylmicronase, prandin, amaryl

Increases insulin productionIncreases insulin production HypoglycemiaHypoglycemia

METFORMINMETFORMIN

GlucophageGlucophage Decreases hepatic glucose Decreases hepatic glucose

productionproduction No hypoglycemiaNo hypoglycemia

TROGLITAZONETROGLITAZONE

RezulinRezulin Increases peripheral glucose Increases peripheral glucose

uptakeuptake No hypoglycemia if used aloneNo hypoglycemia if used alone Initial indication is for pts on insulinInitial indication is for pts on insulin Liver toxicityLiver toxicity

ACARBOSEACARBOSE

PrecosePrecose Alpha-glucosidase inhibitorAlpha-glucosidase inhibitor Decreases glucose uptake in the Decreases glucose uptake in the

gutgut GI intoleranceGI intolerance No hypoglycemiaNo hypoglycemia

COMBINATIONCOMBINATION

Use one from each classUse one from each class Reduce dose of other drugs by 1/2 Reduce dose of other drugs by 1/2

if adding a sulfonylureaif adding a sulfonylurea

INSULININSULIN

Max out oral agentsMax out oral agents Start with intermediate acting Start with intermediate acting

insulininsulin Eventually will use one modalityEventually will use one modality

EVERY VISITEVERY VISIT

FSBSFSBS UA with microalbuminUA with microalbumin Foot exam, including neuroFoot exam, including neuro

EVERY 3 MONTHSEVERY 3 MONTHS

HGB A1CHGB A1C

EVERY 6 MONTHSEVERY 6 MONTHS

LipidsLipids CHEM 8CHEM 8

YEARLYYEARLY

Ophthomology consultOphthomology consult EKGEKG

COMPLICATIONSCOMPLICATIONS

Retinopathy, neuropathy, cad, Retinopathy, neuropathy, cad, nephropathy, enteropathy, poor nephropathy, enteropathy, poor wound healing, impotence, wound healing, impotence, depressiondepression

Hyperglycemia is better than no Hyperglycemia is better than no glycemiaglycemia