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Kevin H McKinney MD
University of Texas Medical Branch at Galveston
Division of Endocrinology/Stark Diabetes Center
DIABETES MELLITUS
•Inability of the body to metabolize
blood sugar
•A disease of inadequate insulin
secretion and action
•Hyperglycemia is the main
manifestation
COMPLICATIONS
•Blindness
•Dialysis
•Lower Limb Amputation
•Stroke
•Myocardial infarction
•Claudication
PRIMARY CLASSES OF
DIABETES MELLITUS
•Type 1
–Autoimmune destruction of islets
–No insulin secretion
•Type 2 Diabetes
–Insulin resistance with progressive insulin
secretory defect
–90% are obese
PREVALENCE OF TYPE 1
DIABETES IN THE US
• 1 million people
CVD
accounts for
Cardiovascular 64% of total
disease
costs
• Contributing factors
–Average delay in diagnosis of 4-7 years
–Longer duration of poorly controlled type 2
diabetes
–Development of equally devastating
complications
MICROVASCULAR COMPLICATIONS OF
DIABETES
•Diabetic retinopathy
–46% higher in African Americans and 86% higher
in Mexican Americans than in Caucasians
•Diabetic Nephropathy
–African Americans, Latinos, and Native Americans
have 3-4 times higher rates of renal failure than
Caucasians
DIABETIC NEUROPATHY
–Glycemic Control
–Smoking Cessation
–Blood Pressure Control
–Lipoprotein Management
–Prothrombotic State Improvement
SCREENING GUIDELINES
• Adults 45 years of age and older esp with BMI > 25
– Fasting Plasma Glucose at 3 year intervals
3819 randomized
60 Microvascular
Adjusted Incidence per
1000 Patient-Years (%)
Complications
40 Myocardial
Infarction
20
0
0 5 6 7 8 9 10 11
Updated Mean A1c (%)*
* Updated mean A1c is adjusted for age, sex, and ethnic group, expressed for white men aged 50-54 years at diagnosis and
with mean duration of diabetes of 10 years.
Stratton IM et al. BMJ. 2000;321:405-412.
Established Modifiable Cardiovascular
Risk Factors In Type 2 Diabetes
UKPDS 23
•Position
in Model Variable P Value*
•First Low-density lipoprotein cholesterol <.0001
* Significant for CAD (n = 280). P values are significance of risk factors after controlling for all other risk factors in model.
Adjusted for age and sex in 2693 white patients with type 2 diabetes with dependent variable as time to first event.
Turner RC et al. BMJ. 1998;316:823-828.
TREATMENT GOALS FOR
DIABETES MELLITUS (Cont.)
Maintaining:
• Blood pressure < 130/80 mm Hg
• LDL Cholesterol < 100 mg/dL,
triglycerides < 150 mg/dL, and HDL
cholesterol > 40 mg/dL in men (> 50
mg/dL in women)
• High risk cardiovascular patients should
aim for LDL cholesterol < 70 mg/dL
MANAGEMENT PLAN
• Must be individualized for each individual
patient
• Diabetes education: initial and subsequent
• Lifestyle modifications
– Diet (improve your nutrition)
– Exercise (increase your activity)
• Home blood glucose monitoring
– At least once/day for oral medications
– Three times daily for insulin users
• Medications
FOLLOW-UP CARE
• Annual eye exam
• Physician visits every 3 months, more
frequently for poor control
– Fundoscopic exam
– Foot exam
• HbA1c quarterly for poor control, every
biannually for good control
• Lipogram yearly
• Microalbumin yearly
Natural History of Type 2 Diabetes
Obesity IGT * Diabetes Uncontrolled
Hyperglycemia
Post-Meal
Plasma Glucose
Glucose
Fasting Glucose
120 (mg/dL)
-20 -10 0 10 20 30
Years of
Diabetes *IGT = impaired glucose
tolerance.
Adapted from International Diabetes Center (IDC), Minneapolis, M innes ota.
MEDICAL NUTRITIONAL
THERAPY
• Must be individualized for each patient
– Children must be allowed enough calories
for growth, development, and activity
– Pregnant women, elderly also deserve
special consideration
• Permanent low-carbohydrate diets not
recommended
– “carbohydrate counting” can be done with
insulin users
MEDICAL NUTRITIONAL
THERAPY (cont)
• Weight management
– One should aim for 500-1000 Calorie reduction in
intake per day
– 1000-1200 Calories/day for women, 1200-1600
Calories/day for men for weight reduction
– Bariatrics?
• Activity should consist of 3-5 sessions per
week
– 30-45 minutes for health
– Weight loss: 1 hour of walking, 30 minutes of
vigorous exercise
ORAL MEDICAL THERAPY
• First line: metformin useful except
where contraindicated
• Sulfonylureas or meglitinides also
frequently used
• Second line: thiazolidinediones
• Used uncommonly: acarbose
INSULIN
• Traditional regimens
– Type 1: Basal insulin (NPH, glargine) with
bolus regular or short-acting insulin
(lispro, aspart, glulisine) by sliding scale;
split-mix regimen; insulin pump
– Type 2: split-mix regimen; fixed
combination (70/30, 50/50, 75/25); basal-
bolus
• Transitional type 2 insulin regimens:
oral agents with bedtime NPH or
glargine
ADJUNCTS
• Cardiovascular
– Aspirin
• Renal
– ACE inhibitor/Angiotensin receptor
blocker
• Hypertension
– Diuretics
• Cholesterol
– Statins
WHEN TO REFER
• Poor control for 6 months despite
patient adherence and physician
manipulation (HbA1c >10%)
• Multiple episodes of decompensation
(DKA, HONK)
• Frequent hypoglycæmic episodes
Reference
• American Diabetes Association.
Diabetes Care 28:S4, 2005 Jan.
• American Association of Clinical
Endocrinologists. Endocrine Practice
8:S40, 2002 Jan/Feb.