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DIABETES MELLITUSDIABETES MELLITUS
THOMAS MILLIGAN, DOTHOMAS MILLIGAN, DO
OSU-COMOSU-COM
FAMILY MEDICINEFAMILY MEDICINE
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IntroductionIntroduction
Types of DMTypes of DM DiagnosisDiagnosis ManagementManagement Follow-upFollow-up ComplicationsComplications
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TYPESTYPES
Type 1Type 1 Type 2Type 2
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TYPE 1TYPE 1
PathophysiologyPathophysiology DiagnosisDiagnosis ManagementManagement
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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
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MANAGEMENTMANAGEMENT
Diet Diet – Decrease GlucoseDecrease Glucose– Pt Pt MustMust Not Skip Meals Not Skip Meals
ExerciseExercise InsulinInsulin
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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
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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
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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
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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
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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
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TYPE 2TYPE 2
PathophysiologyPathophysiology DiagnosisDiagnosis ManagementManagement
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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
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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
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MANAGEMENTMANAGEMENT
DietDiet ExerciseExercise Oral agentsOral agents CombinationCombination InsulinInsulin
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ORAL AGENTSORAL AGENTS
SulfonylureasSulfonylureas MetforminMetformin TroglitazoneTroglitazone AcarboseAcarbose
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SULFONYLUREASSULFONYLUREAS
Diabinese, glucotrol, diabeta, Diabinese, glucotrol, diabeta, micronase, prandin, amarylmicronase, prandin, amaryl
Increases insulin productionIncreases insulin production HypoglycemiaHypoglycemia
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METFORMINMETFORMIN
GlucophageGlucophage Decreases hepatic glucose Decreases hepatic glucose
productionproduction No hypoglycemiaNo hypoglycemia
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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
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ACARBOSEACARBOSE
PrecosePrecose Alpha-glucosidase inhibitorAlpha-glucosidase inhibitor Decreases glucose uptake in the Decreases glucose uptake in the
gutgut GI intoleranceGI intolerance No hypoglycemiaNo hypoglycemia
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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
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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
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EVERY VISITEVERY VISIT
FSBSFSBS UA with microalbuminUA with microalbumin Foot exam, including neuroFoot exam, including neuro
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EVERY 3 MONTHSEVERY 3 MONTHS
HGB A1CHGB A1C
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EVERY 6 MONTHSEVERY 6 MONTHS
LipidsLipids CHEM 8CHEM 8
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YEARLYYEARLY
Ophthomology consultOphthomology consult EKGEKG
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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