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IKA HUDAYANI
POLEWALI PUBLIC HOSPITAL
POLMAN
OUTLINE
Definition
Epidemiology
Pathophysiology
Diagnosis Criteria
Management
Complication
Definition
Group of metabolic
diseases characterized
by hyperglycemia
resulting from defects
in insulin secretion,
insulin action, or both
Classification
Type 1
Type 2
Gestational DM
DM associated
with other
conditions/
syndrome
Epidemiology
In 2030, DM prevalence in Indonesia reached 21.3
million people (Diabetes Care, 2004)
Riskesdas 2007:
ST
OP
DIABET
ES
Regulation of Insulin
Secretion
Intracellular transport of
glucose is mediated by
GLUT-2 (insulin-independent
glucose transporter in cells)
Glucose undergoes oxidative
metabolism in the -cells to yield
ATP
ATP inhibits an inward K+ channel
receptor
Inhibition of this receptor leads to
membrane depolarization, influx of
Ca2+ ions, and release of stored
insulin from -cells
Glucose
uptake
Lipogenesis
Lipolysis
Striated
muscle
Glucose
uptake
Glycogen
synthesis
Adipose
tissue
Insulin
Liver
Gluconeogenesi
s
Glycogen
synthesis
Insulin action on a
target cell
MAP kinase: mitogen-activated protein kinase pathway for insulin &insulin-like growth
factor (mitogenic=proliferation)
PI-3K: phosphatidylinositol-3-kinase (Metabolic activity)
Pathogenesis of T2D
Much less in knownmultifactorial complex disease
1) Environmental factors, such as a sedentary life style
and dietary habits
2) Genetic factors are also involved:
Concordance rate of 35-60% in monozygotic twins
Risk for T2D in an offspring is more than double if both
parents are affected
No HLA association or autoimmune reaction
IR
-cell
dysfunction
Type 2 diabetes
Rhodes CJ & White MF. Eur J Clin Invest 2002; 32
(Suppl. 3):313.
Liver
Glucose output
IR
Adipose
tissue
Muscle
Glucose uptake
Glucose uptake
Hyperglycemia
Glucotoxicity2
Chronic
hyperglycemi
a
Lipotoxicity3
Pancrea
s
High
circulating
free fatty acids
-cell
dysfunction
Boden G & Shulman GI. Eur J Clin Invest 2002; 32:1423.
Kaiser N, et al. J Pediatr Endocrinol Metab 2003; 16:522.
3
Finegood DT & Topp B. Diabetes Obes Metab 2001; 3 (Suppl.
1
Clinical Manifestations
3 Ps: polyuria,
polydipsia, & polyphagia
Fatigue & weakness
Sudden vision changes
Tingling or numbness in
hands/feet
Dry skin
Skin lesions/wounds that
are slow to heal
Recurrent infections
Diagnostic Criteria
A1C 6.5%
OR
A1C 5.76.4%
*For all three tests, risk is continuous, extending below the lower limit of a range and
becoming disproportionately greater at higher ends of the range.
have
additional
risk factors:
Physical
HDL cholesterol level <35
inactivity
mg/dL (0.90 mmol/L) and/or a
First-degree relative with
TG level >250 mg/dL (2.82
diabetes
mmol/L)
High-risk race/ethnicity (e.g.,
Women with polycystic ovary
African American, Latino,
syndrome (PCOS)
Native American, Asian
A1C 5.7%, IGT, or IFG on
American, Pacific Islander)
previous testing
Women who delivered a
baby weighing >9 lb or were Other clinical conditions
diagnosed with GDM
associated with insulin
resistance (e.g., severe
Hypertension (140/90
*At-risk
BMI may
lower
in somefor
ethnic groups.obesity, acanthosis nigricans)
mmHg
orbeon
therapy
History of CVD
hypertension)
ADA. Testing for Diabetes in Asymptomatic Patients. Diabetes Care 2013;36(suppl 1):S14; Table 4.
Management
Education
The purpose of education in DM
Supports the efforts of diabetics to understand the
natural history of the disease & its management
Recognize health problems / complications that may
arise
Adherence monitoring and management of disease
independently (SMBG)
Changes in behavior / health habits
Medical Nutritional
Therapy
Individuals who have prediabetes or diabetes
should receive individualized MNT as needed to
achieve treatment goals, preferably provided by
a registered dietitian familiar with the
components of diabetes MNT
Exercise
Regular physical exercise 3-4 times a week for
30 minutes
Aerobic such as walking, jogging, cycling, and
swimming
To maintain fitness and lose weight and improve
insulin sensitivity
Sulfonylureas/
meglitinides
Biguanides
Carbohydrate
breakdown/
absorption
Insulin
secretion
Glucose output
Insulin resistance
Thiazolidinediones
Insulin
resistance
no dose limit, NPH and Regular are cheap, improve lipids injections, weight gain, hypoglycemia, analogs are
expensive
STEP 1
Healthy life
style
+
Mono therapy
STEP 2
Healthy life
style
+
2 OAD
Combination
Alternative option, if :
No insulin is available
The patient is objecting insulin
Blood glucose is still not
optimally controlled
Healthy life
style
+
3 OAD
Combination
STEP 3
Healthy life
style
+
Combination 2
OAD
+
Basal insulin
Insulin
Intensification*
<7.0%*
70130 mg/dL*
(3.97.2 mmol/L)
<180 mg/dL*
(<10.0 mmol/L)
Good control is
7.0% HbA1c
infarction
HbA1c measures
the average blood
glucose level over
the last 3 months HbA1c
-1%
-14%
Microvascular
complications
-37%
Deaths related
to diabetes
-21%
Source: UKPDS = United Kingdom Prospective Diabetes Study.
Stratton IM et al. BMJ. 2000;321(7258):405-412.
Microvascular Complications:
Nephropathy
Retinopathy
Neuropathy
Foot
ulcers/lesions
Numbness,
pain
Sexual
dysfunction
Gastroparesis
Macrovascular Complications
Cardiovascular
Diseases (CVD)
Coronary Artery
Disease (CAD)
Myocardial
Infarction (MI)
Stroke or
transient
ischemic attack
(TIA)
Peripheral Artery
Disease (PAD)
Acute Complications of
Diabetes
Hypoglycemia50-60 or less
DKA
HHNS
Hypoglycemia
Caused by too much insulin or oral agents, too
little food or excessive physical activity
Surge in epinephrine and norepinephrine
results in sweating, tremors, tachycardia,
palpitations, nervousness and hunger
CNS effectsinability to concentrate, headache,
lightheadedness, confusion, memory problems,
slurred speech, incoordination, double vision,
seizures and even loss of consciousness
Hypoglycemic
unawareness
Related to autonomic neuropathy
Will not experience the sympathetic surgewith
sweating, shakiness, HA, etc
Treatment for
hypoglycemia
Diabetic Ketoacidosis
Clinical features:
1. Hyperglycemia
2. Dehydration and electrolyte
loss
3. Acidosis
3 main causes: illness, undiagnosed & untreated
and decreased insulin
Other causes: patient error, intentional skipping of
insulin
Presentation of DKA
3 Ps
Orthostatic hypotension
Ketosis
GI s/s
Acetone breath
hyperventilation
Diagnostic Findings of
DKA
BS between 300-800
Acidosis
Electrolyte abnormalities
Elevated BUN, creatinine and hct r/t dehydration
Medical Management
of DKA
Rehydrate with normal saline, then follow with .
45% NaCl then D5.45NS (or other)
Restore electrolytes
ECGs
Hourly blood sugars
IV insulin
Avoid bicarbonate as can affect serum K+
Hyperglycemic Hyperosmolar
Nonketotic Syndrome
Predominated by hyperosmolarity and
hyperglycemia
Minimal ketosis
Osmotic diuresis
Glycosuria and increased osmolarity
Occurs over time
Blood sugar is usually over 600
HHNS
Medical Management
Similar treatment as seen in DKA
Watch fluid resuscitation if history of heart
failure
ECG
Lytes monitoring
Fluids with potassium replacement
Thank you
for your
attention