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)
- Sulfonylureas
- Insulin sensitizers (TZDs)
- Pioglitazone (Actos), Rosiglitazone (Avandia)
- Mechanism of action: bind insulin receptors rendering them more sensitive
- Side effects: mild edema, fluid retention