Diabetes

Diabetes

1. Types

   • Dibetes Mellitus
   • Diabetes Insipidus
     • ADH deficiency
   • Secondary Diabetes
     • Physical/emotional stress
       • Prolonged elevation of stress hormones (cortisol & noradrenaline
       • Elevation of glucagon & GH
     • Pregnancy (gestational diabetes)
       • Weight gain & increased oestrogen
     • Drugs
       • Corticosteroids & oral contraceptives antagonise insulin's actions
     • Viral infections
       • Mumps & rubella virus can attack pancreas

2. Diabetes Mellitus

   • Diagnostic indicators
   • Type 1
     • Symptomology
       • Rapidly developing symptoms
       • Muscle wasting
       • Loss of subcutaneous fat
       • Lactosis & acidosis
       • With symptoms apparent, 80% of islets are disabled
       • Anti-insulin and islet antibodies
     • Cause
       • Beta cells in pancreas destroyed or suppressed
       • No insulin produced
     • Treatment
       • Insulin
       • Personalised meal plan
       • Control blood glucose
       • Consistent healthy diet
       • Exercise
     • Insulin-dependent
   • Type 2
     • Cause
       • 1. Insulin resistance at target tissues
       • 2. Overproduction of glucose (inappropriate liver gluconeogenesis)
       • 3. Abnormal insulin secretion
       • 4. Obesity (huge demands on pancreas)
     • Treatment
       • First line treatment
         • Positive lifestyle changes
       • Second line treatment
         • Sensitisers
           • Metaformin (higher uptake of glucose & lower liver glucose output
           • Thiazolidinedione (better use of glucose by cells)
         • Secretagogues
           • Tolubamide, gliclazide (trigger insulin release
             • Must have partially functional beta cells
     • Development
       • 1. Obesity
       • 2. Insulin resistance
       • 3. Hyperinsulinaemia
       • 4. Diminished insulin secretion
       • 5. Type 2 DM
     • Non-insulin dependent
     • 3% UK population (2/3 have type II)
     • Symptomology
       • Vague
       • Slow to develop
       • Long-standing
   • Symptoms
     • Excessive urination (polyuria)
     • Excessive thirst (polydipsia)
     • Excessive eating (polphagia)
     • Weight loss
     • Fatigue & weakness
     • Vision changes
     • Frequent skin infections
     • Dry, itchy skin
     • Vaginal discomfort

3. Pre-diabetic

   • Impaired glucose tolerance
     • Fasting plasma glucose conc <7.0mmol/l
     • 2hr OGTT (Oral Glucose Tolerance Test) >/= 7.8 and <11.1mmol/l
     • 17% of UK 35-65 age group
     • Hyperglycaemia & insulin resistance
     • Asymptomatic (no symptoms)
     • Risk for cardiovascular disease
     • Risk factors
       • Obesity
       • 1st degree rlatives with type 2 DM
       • Asian/Afro-Caribbean
       • Hypertension
   • Metabolic Syndrome
     • Risk factors that increase risk of cardiovascular disease, diabetes & stroke
     • Any 3 of the following:
       • High waist circumference (>102cm men & 88cm women)
       • High triglycerides (>1.7mmol/l)
       • Low HDL cholersterol (<1.03mmol/l men & 1.29mmol/l women)
       • High blood pressure (>130/85mm Hg)
       • Fasting plasma glucose >5.6mmol/l

4. Diagnosis

   • Glycosylated Haemoglobin HbA1c
     • New to diagnostic criteria (Jan 2011)
     • >/=6.5% in venous blood
     • Index of glycaemic control
     • Identifies average plasma glucose conc over time (120days)
     • Poor glycaemic control correlates with long-term complications
     • HbA1c is haemoglobin that is glucose bound
     • Expressed at % glycation
   • Hyperglycaemia
   • Fasting venous blood test >/=7.0mmol/l
   • Glucose tolerance test
     • Fasting blood glucose
     • Blood glucose 0.5 - 3hrs after drinking 75g glucose in 300ml water (30 min intervals)
     • >/=11.1mmol/l

5. Insulin preparations

   • Administered subcutaneously
   • Rate of absorption can be varied by
     • Increase particle size
     • Complex insulin with zinc
   • Short acting
     • Onset 30mins; Peaks 2-4hrs; subsides 8hrs
   • Intermediate/Long acting
     • 16-35hrs
     • Semilente
   • Fast acting
     • Lispro/Aspart

6. Self-monitoring

7. Screening

   • Increased risk
     • >40
     • Obesity
     • Asian/Afro-Caribbean
     • Family history of Tyoe 2
     • History of gestational diabetes
     • History of large baby >4Kg
   • Why Screen?
     • Type 2: 9-12 year latency
     • Prevent macrovascular changes (atherosclerosis, hypertension, stroke & MI); and microvascular changes (nephropathy, retinopathy, neuropathy)
   • BMI
     • =Weight (Kg) / Height x Height (m)
       • <18.5 underweight
       • 18.5-25 normal
       • 25-30 overweight
       • >30 obese

8. Glycaemia & Ketosis

   • Hypo
     • Sudden moodiness
     • Jerky movements
     • Difficulty paying attention
     • Tingling sensations around mouth
   • Hyper
     • Causes: Eating more than planned; exercising less than planned; the stress of an illness
   • Ketosis
     • Build up of ketone bodies from lipid breakdown in liver
     • Can cause acidotic state & diabetic coma
     • Shortness of breath, fruity smell; nausea & vomiting; dry mouth

9. Quick treatment

   • If a diabetic patient passes out from hypoglycemia:
   • NOT inject insulin
   • NOT give food or fluids
   • DO inject glucagon

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