Diabetes

Type 1 & Type 2

  • Type 1: autoimmune destruction of pancreatic beta cells – absolute insulin deficiency
  • Type 2: insulin resistance with relative insulin deficiency OR secretory defect with insulin resistance

Diagnosing diabetes

  • Random blood glucose ≥11.1 mmol/L with symptoms (fatigue, polyuria, polydipsia, unexplained weight loss)
  • Fasting blood glucose ≥7.0 mmol/L
  • Fasting blood glucose in 2 hr OGTT ≥11.1 mmol/L

Impaired fasting blood glucose

  • Fasting blood glucose 5.7 – 6.9 mmol/L with risk factors
    • Screen with  2hr OGTT
  • Fasting blood glucose 6.1 – 6.9 mmol/L no risk factors

Screening

  • Every 3 years in those ≥40yo with no risk factors
  • Earlier and more frequently if risk factors (10 FHx, high risk population, Hx IGT/IFG, presence of complications associated with DM, vascular disease, Hx GDM, overweight, HTN, dyslipidemia, PCOS, schizophrenia, acanthosis nigricans, etc.)



 

Management of T2DM

  • Lifestyle modifications: diet and physical activity (2-3 months)
  • First line antihyperglycemic agents:
    • In overweight individuals – biguanide
    • Sulphonylurea
    • Alpha-glucosidase inhibitor
  • Combination treatment if target not achieved on monotherapy
  • Insulin therapy if target no achieved on  combination therapy

Complications of diabetes

  • Neuropathy
    • ANS (impotence, constipation, diarrhea, gastroparesis, orthostatic hTN)
    • Peripheral (anesthetic, paresthetic, hyperesthetic)
  • Retinopathy
  • Nephropathy
  • CVS
  • Foot care
  • Hospitalizations for poor control (DKA, hyperosmolar nonketotic coma, hypoglycaemia)

Antihyperglycemic agents

  • Alpha-glucosidase inhibitor
    • Acarbose (Prandase)
    • Mechanism of action: delays glucose absorption
    • Side effects: GI
    • Contraindications: IBD
  • Biguanide
    • Metformin (Glucophage)
    • Mechanism of action: inhibits hepatic glucose release; enhances peripheral muscle glucose uptake and utilization
    • Side effects: GI
    • Contraindications: renal or hepatic dysfunction, cardiac failure
  • Insulin secretagogues
    • Sulfonylureas
      • Gliclazide (Diamicron), Glimepiride (Amaryl), Glyburide (Diabeta, Euglucon)
      • Mechanism of action: increase pancreatic insulin releas
    • Non-sulfonylureas
      • Nateglinide (Starlix), Repaglinide (GlucoNorm)
  • Insulin sensitizers (TZDs)
    • Pioglitazone (Actos), Rosiglitazone (Avandia)
    • Mechanism of action: bind insulin receptors rendering them more sensitive
    • Side effects: mild edema, fluid retention

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