Ibrahim alzarga

DIABETES R2
SUPERVISED BY

MELLITUS DR.Marwa
Family medicine
consultant
  Definition

 Epidemiology

 Classification of DM.

 Criteria for diagnosis of DM.

Objectives.  Criteria for defining prediabetes

 Prevention or Delay of Type 2 Diabetes

 Evaluation of DM.

 Complications of DM.
What is diabetes?

Diabetes is a metabolic disorder

characterized by hyperglycemia due to
Lack of insulin secretion (beta cell
destruction) and/or irresponse to
insulin in target tissues (insulin resistance).
:Classification of DM
Type I DM:
 Autoimmune destruction of b cells.
 Absolute insulin deficiency

Type II DM:
 Progressive loss of adequate insulin
secretion

Specific Types of DM:

monogenic diabetes syndromes
exocrine pancreas
drug- or chemical-induced diabetes

GDM:
 Diabetes diagnosed in the 2nd or 3rd
trimester of pregnancy.
 Type I Diabetes:
 Characterized by autoimmune destruction
of the pancreatic beta cells, leading to
absolute insulin deficiency.

 5 to 10% of DM among adults.

 Typically present with the hallmark

Classification symptoms of polyuria/polydipsia, and

approximately

of DM.
 one-third present with diabetic ketoacidosis
(DKA).

 Presence of two or more islet

autoantibodies is a near certain predictor of
clinical hyperglycemia and diabetes Type I.

 Usually associated with other auto-immune

diseases: thyroid, celiac, and rarely Addison
disease.
 Type I Diabetes:
5 Auto autoantibodies:

 Glutamic acid decarboxylase (GADA).

Classification  Islet cell antibody (ICA).
of DM.  Islet tyrosine phosphatase (IA2).

 Insulin autoantibody (IAA).

 Zinc transporter 8 A (ZnT8A).

 Type II Diabetes:
 Most common type of diabetes in adults.

 90-95 % of all diagnosed cases of diabetes.

 Characterized by hyperglycemia, insulin resistance, and

relative impairment in insulin secretion.

Classification  Type 2 diabetes often presents on a background genetic

predisposition and is characterized by insulin resistance
and relative insulin deficiency.
of DM.  Insulin resistance is aggravated by aging, being
overweight (body mass index [BMI] 25.0 to 29.9
kg/m²), and obesity (BMI >30 kg/m²) in particular.
 Symptomatic patients may present with : fatigue;
polyuria, polydipsia, polyphagia, or weight loss (usually
when hyperglycemia is more severe [e.g., >16.6
mmol/L, >300 mg/dL]); blurred vision; paresthesia; skin
infections (bacterial or candida); urinary tract infections;
or acanthosis nigricans.
 .Classification of DM

T1DM T2DM GDM DM due to other causes

A Diabetes Monogenic diabetes

diagnosed syndromes (such as neonatal
progressi diabetes and maturity-onset
Autoimm in the
ve loss diabetes of the young
une β-cell second or [MODY])
of b-cell
third
insulin
destructio trimester Diseases of the exocrine
secretion
n, usually of pancreas (such as cystic
leading to pregnanc fibrosis and pancreatitis)
frequentl
absolute y that
y on the Drug- or chemical-induced
insulin was not
backgro diabetes (such as with
deficiency clearly
und of glucocorticoid use, in the
overt
insulin treatment of HIV/AIDS, or
diabetes
resistanc after organ transplantation)
prior to
e
gestation
FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no
*.caloric intake for at least 8 h
OR
DIAGNOS
IS OF
h PG ≥200 mg/dL (11.1 mmol/L) during OGTT. The test -2
should be performed as described by WHO, using a
glucose load containing the equivalent of 75 g anhydrous

DIABETE
*.glucose dissolved in water
OR
A1C ≥6.5% (48 mmol/mol). The test should be performed
in a laboratory using a method that is NGSP certified and
*.standardized to the DCCT assay
S.
OR
In a patient with classic symptoms of hyperglycemia or
hyperglycemic crisis, a random plasma glucose ≥200
.mg/dL (11.1 mmol/L)
  If a patient has discordant results from 2
different tests?
The test result above the diagnostic cut point
should be repeated.

Confirming  If a patient meets the diabetes criterion of

the the A1C twice but not FPG?

.Diagnosis
The patient has DM, Two abnormal test
results, either from the same sample or in two
separate samples.

 Marked discordance between measured

A1C and plasma glucose levels
Hemoglobin variants i.e.,
hemoglobinopathies.
 .Prediabetes

Prediabetes is associated with obesity (especially

abdominal or visceral obesity), dyslipidemia with It is a risk for progression to diabetes
high triglycerides and/or low HDL, and and cardiovascular disease.
hypertension).
FPG 100 MG/DL (5.6 MMOL/L) TO 125
MG/DL (6.9 MMOL/L) (IFG)

OR

2-h PG during 75-g OGTT 140 mg/dl (7.8 mmol/L)

to 199 mg/dl (11 mmol/L) (IGT)
CRITERIA
OR
DEFINING
PREDIABETES.
A1C 5.7-6.4%

FPG: fasting plasma glucose, IFG: impaired

fasting glucose, IGT: impaired glucose tolerance,
OGTT: oral glucose tolerance test. 2-h PG: 2 h
plasma glucose *For all three tests, risk is
continuous, extending below the lower limit of the
range and becoming disproportionately greater at
the higher end of the range.
 ■ What are the criteria for screening for
.Screening diabetes or prediabetes in asymptomatic
adults?
Testing should be considered in adults who are overweight or obese (BMI > 25
kg/m2 or > 23 kg/m2 in Asian Americans) and have one or more of the following
risk factors:
– First-degree relative with diabetes
– High-risk race/ethnicity (e.g., African American, Latino, Native American, Asia
American, Pacific islander)
– History of CVD
– Hypertension (>140/90 or on therapy for hypertension)
– HDL cholesterol level < 35 mg/dl and/or a triglyceride level > 250 mg/dl Criteria for
– Women with polycystic ovary syndrome
– Physical inactivity
screening for
– Other clinical conditions associated with insulin resistance (e.g., severe obesity, diabetes or
acanthosis nigricans)
prediabetes in
Patients with prediabetes (A1C > 5.7% [39 mmol/mol], IGT, or IFG) should be
tested yearly. asymptomatic
Women who were diagnosed with GDM should have lifelong testing at least every 3 adults.
years.
For all other patients, testing should begin at 35 years old.

People with HIV

If results are normal, testing should be repeated at a minimum of 3-year intervals,
with consideration of more frequent testing depending on initial results and risk
status.
CVD: cardiovascular disease, GDM: gestational diabetes, IFG: impaired fasting
glucose, IGT: impaired glucose tolerance.
Screening should be considered in youth* who are overweight
(>85th percentile) or obese ( >95th percentile) and who have one or
more additional risk factors based on the strength of their
:association with diabetes
Risk-based screening
Maternal history of diabetes or GDM during the child’s gestation – for DM or
prediabetes in
.Family history of DM2 in first or second degree relative –
asymptomatic
Race/ethnicity (e.g., African American, Latino, Native American, – children and
Asia American, Pacific islander) adolescents.
Signs Of insulin resistance or conditions associated with insulin –
resistance (acanthosis nigricans, hypertension, dyslipidemia,
polycystic ovary syndrome, or small-for-gestational-age birth
weight)
GDM: gestational diabetes, * After the onset of puberty or after 10 years
of age, whichever occurs earlier. If tests are normal, repeat testing at a
minimum of 3- year intervals (or more frequently if BMI is increasing or
.risk factor profile deteriorating) is recommended
 Prevention or Delay of Type 2 Diabetes.

Patients should be monitored and tested per screening guidelines

Refer adults who are overweight or obese at high risk for diabetes for intensive lifestyle
modification.

Intensive lifestyle behavior change program:

As per Diabetes Prevention Program (DPP) trial, it reduces the risk of DM2 by 58% over 3 years

Goal is to achieve or maintain 7% loss of initial body weight

Dietary plans for eating patterns can be associated with lower risk for diabetes such as vegetarian,
Mediterranean, dietary approach for hypertension (DASH), plant-based

Physical activity at least 150 min/week of moderate intensity such as brisk walking
 Metformin should be considered in adults
with prediabetes aged 25–59 years old with:

 BMI >35 kg/m2

Medication for  high fasting glucose >110 mg/dl
 higher A1c >6%
the prevention
of DM2.
Other medication (as per DDP trail)
 Alpha-glucosidase inhibitors
 Liraglutide
 Thiazolidinediones
 .Approach to patients with diabetes (History)

2- Controlled or not controlled : Home

1- Diabetes history: Age at onset (disease
glucose readings: All pts on insulin; ask pt
duration), medications used, prior
to bring glucometer to every visit;
glycemic control, known complications,
examine for highs/lows/patterns, if lows
previous hospitalization.
assess hypoglycemia awareness.

4- Behaviors: Physical activity, dietary

3- Symptoms of hyper/hypoglycemia.
habits, sleep pattern .
 Approach to patients with diabetes
.(History)

8- Renal: CKD risk factors (HTN),

7- Ophtha: blurry Vision , decreased
review prior urine Alb/Cr ratios, and
visual acuity , last retina check up .
Cr.

9-Peripheral neuropathy: Often starts 10- Autonomic neuropathy: orthostatic

feet burning at night. Hypotension, gastroparesis.
 Physical
Examination:
 Height, weight, and BMI.

 Blood pressure determination.

 Orthostatic blood pressure measures (when

indicated).

 Fundoscopic examination (refer to eye

specialist).

 Thyroid palpation.

 Skin examination for Insulin resistance signs (eg,

acanthosis nigricans, skin tags)
 for the insulin injection site to check for
lipodystrophy.
  AIC (every 3-6m).
 Blood glucose: FBG, PPG, RBG.

 Lipid profile including ( LDL and HDL, total

cholesterol, and triglycerides ).
 Liver function tests.

Laboratory
investigation
 Spot urinary albumin-to-creatinine ratio annually.
 Serum creatinine and estimated glomerular
filtration rate.
.
 Thyroid-stimulating hormone in patients with type
1 diabetes.
 Vitamin B12 if on metformin (when indicated).

 Serum potassium levels in patients on ACE

inhibitors, ARBS, or diuretics.
Comprehensive
Medical
Evaluation and
Assessment of
Comorbidities.
 Vaccination is important for all pt with
diabetes as a part of prevention of further
complication and decreasing mortality
you have to offer vaccine for the
following :

Immunization 1. Influenza
. 2. Pneumococcal pneumonia
3. HBV
4. HPV
5. Tdap
6. Zoster
 Assessment of Glycemic Control.

A1C test

Self-monitoring of blood glucose (SMBG)

Continuous glucose monitoring (CGM)

Self-monitoring of
blood glucose
(SMBG) :
 Allows patients to assess
their individual response to
therapy.

 Integrating test results for

self-management in
relation to meals, exercise,
and in acute illnesses.

 SMBG yields better

glucose control, especially
in patients using insulin.
Continuous glucose
monitoring (CGM).

 Carries a vital role in prevention and treatment of

hypoglycemia in patients with DM1 and patients
with DM2 who are taking intensive insulin
regimens
  It is the primary test for assessing
glycemic control over 2 – 3 months which
has a substantial predictive value for
diabetic complications.

.A1C test  It should be performed routinely with an

initial assessment and as part of follow-up
where fasting is not required.

 The test is stable during acute illnesses.

 Acute:
Diabetes 
Diabetic keto acidosis (DKA)
Complications 
Hyperglycemic hyperosmolar syndrome
(HHS)
. 
Hypoglycemia
 Diabetes Complications

Chronic
Microvascular Macrovascular
- Nephropathy - Coronary Artery disease (CAD)
- Retinopathy - Peripheral Artery disease (PAD)
- Neuropathy ( autonomic-peripheral) - Cerebrovascular disease (CVD)
 The risk of ulcers or amputations is increased
in people who have the following risk factors:

 Poor glycemic control

 Peripheral neuropathy with LOPS
 Cigarette smoking
 Foot deformities

Cont.  Pre-ulcerative callus or corn

 PAD
 History of foot ulcer
 Amputation
 Visual impairment
 CKD (especially patients on
dialysis)
 patients found to have elevated blood pressure ($140/90
Blood pressure should be measured at mmHg) should have blood pressure confirmed using
every routine clinical visit multiple readings, including measurements on a separate
day, to diagnose hypertension.
Cardiovascular Disease and Risk Management

Statin Treatment—Primary Prevention.

10.19 For patients with diabetes aged 40–75 years without atherosclerotic
cardiovascular disease, use moderate-intensity statin therapy in addition to
lifestyle therapy. A
  HbA1c every 3-6 months.
 Urine analysis for micro-albumiurea annually at
diagnosis for type 2 and after 5 years of
diagnosis for type1.

 Dilated eye exam annually at diagnosis for type 2

Patient with and after 3-5 years after diagnosis for type1.
 Assessment for distal symmetric polyneuropathy

DM require
should include a careful history and assessment
of either temperature or pinprick sensation (small
fiber function) and vibration sensation
using a 128-Hz tuning fork (for large fiber
function).

 All patients should have annual 10-g

monofilament testing to identify feet at risk for
ulceration and amputation.
Screening ■ Patients with type 2 diabetes or
for Fatty prediabetes and elevated liver enzymes
(ALT) or fatty liver on ultrasound should

Liver
be evaluated for the presence of
nonalcoholic steatohepatitis and liver
fibrosis.

disease.
References:
THANK YOU.