From " Mad medics"
• Diabetes mellitus:
• diabetes “to pass through”
• mellitus “honey”
• Diabetes is a condition where insulin is not produced in sufficient quantities or works less efficiently at its target sites, due to Abnormalities of metabolism (fat & protein as well as carbohydrate) ,Resulting in high blood sugar (hyperglycaemia)
“systemic disease characterised by hyperglycaemia”
*Clinical presentation - symptoms & signs
1. Thirst
2. Weight loss
3. Polyuria
4. Nocturia
5. Visual changes
6. Lethargy
7. Pruritis vulvae
8. Balanitis
9. Neuropathic symptoms (pain, numbness)
Classification of diabetes
• Type 1 diabetes mellitus
• Type 2 diabetes mellitus
• Gestational diabetes mellitus
• Specific types of diabetes mellitus
1. Type 1 diabetes mellitus
• Usually presents during childhood or adolescence
• Weight loss, Polyuria, Polydypsia
• Often present with ketoacidosis
• Insulin therapy is essential
• Most due to immune mediated processes
• May be a/w other AI diseases such as Addison’s disease, vitiligo, Hushimoto’s thyroiditid etc.
• Individuals with HLA types DR3 & DR4 of major histocompatibility complex are most at risk .
• Autoantibodies found in ~ 90% of cases
– to islet cells (ICA), insulin, tyrosine phosphatases IA-2 and IA-2β and glutamic de-carboxylase
• Idiopathic DM
– not immune mediated
– strongly inherited
– more common in black and Asian people
• Latent Autoimmune diabetes of adults (LADA)
Latent Autoimmune diabetes of adults
(LADA)
• Islet antibodies present at diagnosis of diabetes, but progression of autoimmune βcell failure is slow
• Not insulin requiring, at least during the first 6 months after diagnosis
• In phenotypic type 2 diabetes patients
– LADA occurs in 10% of individuals older than 35 years and in 25% below that age
2. Type 2 Diabetes Mellitus
• A complex heterogeneous group of metabolic disorders including hyperglycemia and impaired insulin action and/or insulin secretion
• Spectrum of disorders ranging from mainly insulin resistance with relative insulin deficiency to a predominantly secretory defect with insulin resistance
Type 2 diabetes mellitus
• ~ 90% of all diabetes case
• Onset most usually in adult life
• Familial tendency & an association with obesity
• Spectrum of disorders ranging from mainly insulin resistance with relative insulin deficiency to a predominantly secretory defect with insulin resistance
• Current theories
– defect in insulin-mediated glucose uptake in muscle
– dysfunction of the pancreatic β-cells
– Dysfunctional adipocytes
– impaired insulin action in liver
• ~ 90% of all diabetes case
• Onset most usually in adult life
• Etiology is multifactorial
– Genetic background
– environmental factors
• Patterns of inheritance is both polygenic and heterogeneous – i.e. multiple genes are involved and different combinations of genes play a role in different subsets of individuals
3.Gestational diabetes mellitus
Diabetes mellitus during pregnancy, It can affect your child's health.
4. Other specific types of DM
• Genetic defects of β cell function
– MODY
• Genetic defects of insulin action
– Type A insulin resistance (insulin receptor defect)
• Insulin deficiency due to pancreatic disease
– Chronic pancreatitis, pancreatectomy, haemochromatosis, cystic fibrosis
• Endocrinopathies
– Relative insulin deficiency- acromegaly, Cushing’s syndrome, phaeochromocytoma
Other specific types of DM ctd.
Criteria for Diabetes Diagnosis
• Hb A1C ≥6.5% (48 mmol/mmol)
– Perform in a lab using NGSP-certified method and standardized to DCCT assay
• FPG ≥126 mg/dL (7.0 mmol/L)
– Fasting defined as no caloric intake for ≥8 hrs
• 2-hr PG ≥200 mg/dL (11.1 mmol/L) during OGTT (75-g anhydrous glucose)
– Performed as described by the WHO
• Random PG ≥200 mg/dL (11.1 mmol/L)
– In persons with symptoms of hyperglycemia or hyperglycemic crisis
• In the absence of unequivocal hyperglycemia results should be confirmed using repeat testing
Categories of Increased Risk for Diabetes (Pre-diabetes)
– FPG 100 - 125 mg/dL (5.6 - 6.9 mmol/L) OR
• Impaired Glucose Tolerance (IGT)
– 2-hr PG in 75-g OGTT 140 - 199 mg/dL (7.8 -
11.0 mmol/L)
OR
• hbA1C 5.7%-6.4%
• Type 2 diabetes testing should be done in all adults who are overweight or obese (BMI ≥25 or ≥23 in Asian Americans) and have additional risk factors
• Testing should begin at the age of 45 years
Diabetes Risk Factors
– Physical inactivity
– First-degree relative with diabetes
– High-risk race/ethnicity
– Women who delivered a baby >9 lb 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, PCOS
– CVD history
Who should be screened?
Sri Lankan guidelines
• Use opportunistic screening – on adults >35 years whenever there is an opportunity
• Individuals <35 yrs should be tested if they are at high risk of developing type II diabetes
– Risk factors
• IGT/IFG
*first degree relatives with diabetes
• Inactive lifestyle or overweight (BMI >25)
• Metabolic syndrome
• Hypertension or dyslipidaemia
• Cardiovascular disease (MI, angina or stroke) & PAD
• PCOD or previous GDM
• H/O having large babies (>3.5 kg)
Pre-diabetes testing
• To test for pre-diabetes, the HbA1C, FPG, and 2-h PG after 75-g OGTT are appropriate
• If tests are normal, repeat testing carried out at a minimum of 3- year intervals is reasonable
• In patients with pre-diabetes, identify and, if appropriate, treat other cardiovascular disease (CVD) risk factors
• Testing to detect pre-diabetes should be considered in children and adolescents who are overweight or obese and who have ≥2 additional risk factors .
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