Diabetes mellitus 

ERRATA:
Dulaglutide is not a sulfonylurea but a GLP1 agonist.
This is a short overview of diabetes mellitus.
Additional notes:
-Don't use HbA1c to screen for gestational diabetes -- the 2-3 month time window is too long!
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Pathogenesis Symptoms Screening / diagnosis Non-insulin treatment (DM2) Insulin (DM1&2) Acute complications Chronic Overview of diabetes mellitus Type 1 Autoimmune destruction beta cells in pancreas Insulin-producing release exosomes → taken up by dendritic presented to T Detect autoantibodies: GAD65 & IA-2 90% destroyed DM1 Low endogenous insulin Sudden onset 2 is still produced (at first) But body’s resist does not work as well Risk factors Obesity Age (↓ with age) Genetics Gradual Manu5, CC BY-SA 4.0 creativecommons.org/ licenses/by-sa/4.0, via Wikimedia Commons Mikael Häggström, Public domain, Screen: age 45, hypertension, BMI 25 Test Normal range IGT (prediabetes) Diabetes Random blood glucose (mg/dL) - 200 + symptoms 2-hr oral tolerance test 140 140-200 Fasting 100 100-125 125 Hba1c (%) 5.7 5.7-6.5 6.5 Treatment: Goal: a1c 7% Lifestyle (diet/exercise) metformin another agent; when 9% polydipsia, polyuria, numbness/tingling hands/feet 2hr OGTT and fasting BG require two readings on separate days Class/drugs Mechanism Notes side effects Biguanides: ↑ sensitivity Diarrhea starting; don’t use liver dz, CKD, CHF lactic acidosis; hospitalized GLP1/incretin mimetics (-tide): liraglutide, exenatide GLP1/incretins, which suppress glucagon Weight loss DPP4i (-gliptins): saxagliptin, sitagliptin, alogliptin Inhibit DPP4 increase incretins GLP1 neutral Thiazolidinediones (TZDs): pio-, rosi-, lobeglitazone gain Sulfonylureas (gl-): glyburide, glipizide, dulaglutide secretion Hypoglycemia Meglitinides (-glinide): repaglinide, nateglinide (but without sulfa) Alpha-glucosidase inhibitor: acarbose, miglitol ↓ small intestine carb absorption Gas, diarrhea, abd pain SGLT2i (-flozin) kidney reabsorp UTIs/fungal infxns, euglycemic DKA Best Worst Long acting basal (for nightly): Lantus (glargine); Levemir (detemir) Intermediate-acting insulin: NPH Rapid prandial meals): Novolog (aspart); Humalog (lispro); Regular Combo insulins twice daily): Novolin 70/30 NPH/regular; Humulin NPH/regular Jakob Suckale, Michele Solimena, BY 3.0 creativecommons.org/licenses/..., Hypoglycemia: Causes: ↑↑ insulin, ↓↓ food, exercise Blood 70 and/or (perspiration, palpitations, AMS, diabetic coma) if awake; IVD50 coma Hyperglycemia: Diabetic ketoacidosis (DKA) Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS HHS) DM Pathophysiology body needs energy break down fatty acids ketosis high excessive urination dehydration higher b.g. ... (altered mental status, unconscious) Seizures? Less common More 300-500 800-900 Urinalysis Ketones No ketones Arterial gas Acidosis (pH 7.3) acidosis Basic metabolic panel Anion gap (low bicarb) anion (normal Mortality 5-10 10-20 Treatment IV fluid bolus, replete potassium How do we know stop treating? Check Microvascular Macrovascular atherosclerosis MI, CHF, stroke, PVD Retinopathy Nonproliferative hemorrhages, exudates, vessel dilation ischemia or edema macula Proliferative neovascularization: new formation vitreous hemorrhage retinal detachment blindness annual exam laser photocoagulation shrink vessels Nephropathy Nodular diffuse glomerulosclerosis hyaline deposition; glomerular basement membrane thickening urinalysis microalbumin/creatinine ratio ACEi/ARB Neuropathy Numbness/paresthesias longest nerves first: hands feet ulcers; (Charcot joints) Autonomic neuropathy neurogenic bladder, gastroparesis, postural hypotension, impotence (men), constipation/diarrhea artery dz microvascular = foot ulcers/infxns/claudication pt notice no healing last resort amputation monofilament wire exam; podiatrist; education gabapentin for painful hypersensitive www.scientificanimations.com/, creativecommons.org/licenses/...,