Diabetes Mellitus

Study guide:

Definitions:  

  • Clinical syndrome characterized by chronic hyperglycemia and metabolic abnormalities.

 

Epidemiology:

  • 34.1% in adult males and 27.6% in adult females in the Saudi community.

  • Estimated ~150 million people have DM worldwide.

  • Amongst the Leading causes of adult onset blindness, kidney failure, and non-traumatic lower limb amputations.

 

Types:

Clinical Presentation:

  • Classical presentation of marked hyperglycemic state:

    • Polyuria

    • Nocturia

    • Enuresis

    • Lethargy

    • Fatigue

    • Polydipsia

    • Polyphagia

    • Recent sudden weight loss

    • Abdominal pain

  • 30% of DM type I patients present with Diabetic ketoacidosis (DKA).

  • Patient who do not seek routine medical check usually present with one of the complications of DM, which is usually seen among DM type II patient. 

Diagnosis:

Screening:

  • DM1: Subclinical prodrome can be detected in 1st and 2nd-degree relatives of those with DM1 by the presence of pancreatic islet autoantibodies.

  • DM2: (in asymptomatic adults):

    • Overweight or obese (BMI ≥25 or ≥23 in Asian Americans) who have ≥1 diabetes risk factor.

    • Begin at age 45, especially if overweight or obese.

    • If normal results: repeat testing in ≥3-yr intervals.

Managment:

  •  Non-pharmacological:

    • Lifestyle modifications:

    • Weight loss (DM type II).

    • Physical activity (according to ADA 2015 guidelines): check the table below.

    • Smoking cessation including e-cigarettes.

    • Bariatric surgery in type II DM (for BMI≥35). 

  • Pharmacological:

    • Oral hypoglycemic agents.

    • Insulin. 

Diabetes risk factors:

  • Physical inactivity

  • First-degree relative with diabetes

  • High-risk race/ethnicity

  • Women who delivered a baby > 9 lbs. or were diagnosed with GDM

  • HDL-C <35 mg/dL ± TG >250 mg/dL

  • Hypertension (≥140/90 mm Hg or on therapy)

  • A1C ≥5.7%, IGT, or IFG on previous testing

  • Conditions associated with insulin resistance: severe obesity, Acanthosis Nigricans, and PCOS.

  •  CVD history 

Chronic Complications:

  • Microvascular:

    • Retinopathy:

      • Nonprolirative (most common).

      • The leading cause of blindness in the USA. 

    • Nephropathy:

      • Protein loss.

      • Nodular glomerular sclerosis (Kimmelsteil-Wilson syndrome).

      • Screening is done by checking for Microalbuminurea

      • The leading cause of renal failure.

    • Neuropathy:

      • Peripheral neuropathy:

        • Sensory and motor weakness.

        • The main cause of skin ulcers in the feet is decreased sensation due to peripheral
          neuropathy.

        • The leading cause of non-traumatic limb amputations in USA. 

      • Autonomic neuropathy:

        • Erectile dysfunction in men (most common presentation).

        • Postural hypotension.

        • Neurogenic bladder.

        • Gastroparesis.

        • Constipation and diarrhea. 

  • Macrovascular:

    • Atherosclerosis:

      • Increased risk of MI (silent) and CHF.

      • DM is a CAD risk equivalent.

      • Main cause of death.   

    • Cerebrovascular disease.

    • Peripheral vascular disease. 

Acute Complications:

  • Hypoglycemia:

    • The primary organ at risk of hypoglycemia is the brain.

    • Physiologic response to hypoglycemia:

      • Glucagon is the first line defense (BG<80mg/dL).

      • Then in order epinephrine and cortisol.

    • Symptoms of hypoglycemia start when BG≤50mg/dL:

      • Sympathetic activation: tremors, sweating, tachycardia, ↑ BP and HR, and anxiety .

      • Neuroglycopenic: irritability, drowsiness, behavioral changes, headache, confusion, seizures, coma, and death in severe cases.

    • Manage by giving sugar rich food if the patient can eat. If not, administer 1\2-2 ampules of D50W IV.  

Health Maintenance:

  • BP target for should be <130\80, and the drug of choice is ACE inhibitors or ARBs. o ACEi and ARBs have renal protective effect to prevent proteinuria.

  • LDL target should be <100.

  • Each follow up visit screen for complications.

  • Educate the patients on their diet and foot care.

  • Annual foot examination.

  • Annual ophthalmology exam.

  • Annual screening for microalbuminuria through albumin\creatinine ratio.

  • Aspirin should be given to all diabetics > 30Y/O.

  • Vaccines: Pneumococcal and influenza vaccines. 

 

References:

  • Kumar, Parveen J, and Michael L Clark. Kumar & Clark's Clinical Medicine. Print.

  • Howland, Richard D et al. Pharmacology. Philadelphia: Lippincott Williams & Wilkins, 2006. Print.

  • Hldemo.ebscohost.com,. '| Diabetes Mellitus Type 2 In Adults'. N.p., 2015. Web. 5 Nov. 2015.

  • Haas, L. et al. 'National Standards For Diabetes Self-Management Education And Support'. Diabetes Care 37.Supplement_1 (2013): S144-S153. Web. 5 Nov. 2015.

  • Hall, Justin, and Azra Premji. Toronto Notes For Medical Students, Inc. © 2015. 2015. Print.

  • Agabegi, Steven S, Elizabeth D Agabegi, and Adam C Ring. Step-Up To Medicine. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2013. Print.

  • Fischer, Conrad. Master The Boards. Print.

  • Perez, Mayra, Lindsay K Botsford, and Winston Liaw. Déjà Review. New York: McGraw-Hill Medical, 2011. Print.

  • (DM), Diabetes. 'Diabetes Mellitus (DM) - Endocrine And Metabolic Disorders'. Merck Manuals Professional Edition. N.p., 2015. Web. 5 Nov. 2015.

  • Emedicine.medscape.com,. 'Type 1 Diabetes Mellitus: Practice Essentials, Background, Pathophysiology'. N.p., 2015. Web. 5 Nov. 2015.

  • Al-Rubeaan, Khalid et al. 'Epidemiology Of Abnormal Glucose Metabolism In A Country Facing Its Epidemic: SAUDI-DM Study'. Journal of Diabetes 7.5 (2014): 622-632. Web.

  • Aljabri, KhalidS, SamiaA Bokhari, and KhalidA Alqurashi. 'Prevalence Of Diabetes Mellitus In A Saudi Community'. Annals of Saudi Medicine 31.1 (2011): 19. Web.

  • ProProfs,. 'DIABETIC FOOT'. N.p., 2015. Web. 5 Nov. 2015. (Figure1). 

 

 

 

 First author:    Lama Al Luhidan


Second author:  Roaa Amer


Reviewed by:    Abdullah AlAsaad
                           Haifa Al Issa
                           Husam Al Tahan


Format Editor:  Adel Yasky 

                          Bayan Alzomaili

Audio recording:


Read by: Thekra AlGholaiqa


Directed by: Rana Alzahrani


Audio production: Bayan Alzomaili