Diabetes Mellitus
Definition
Impaired glucose metabolism secondary to an absolute/relative insulin deficiency or
decreased sensitivity, or both
Diagnostic criteria (SEMDSA 2012)
1
Clinical features
Polyuria
Polydipsia
Polyphagia with unexplained weight loss
Can be asymptomatic
Complications (NB!!)
Acute Uncontrolled hyperglycaemia, DKA, HHS (hyperosmolar hyperglycaemic
state)
Chronic Microvascular, macrovascular or avascular (infection)
Microvascular
Neuropathy
o Peripheral neuropathy (symmetrical)
Glove and stocking sensory loss
Paraesthesia
Motor loss
o Autonomic neuropathy
Gastroparesis
Neurogenic bladder
Impotence
Orthostatic hypotension
o Mononeuropathy
Sudden onset peripheral or CN deficit (e.g. foot drop)
Retinopathy
o Non-proliferative (damage)
‘dot and blot’ and retinal haemorrhages, cotton wool/protein
exudates
o Proliferative
Neovascularization, retinal detachment, blindness
o Both treated with photocoagulation
Nephropathy
o Microalbuminuria Proteinuria +/- Nephrotic syndrome Renal failure
o Glomerular basement membrane thickening
o Rx BP control, ACE-I, low protein diet
2
Macrovascular
Atherosclerosis (DM is high risk for MI, CVA, foot ulcers)
o Stroke
o CAD MI
o Peripheral arterial disease (PAD) NB Ulcers
Avascular
Diabetic foot (microvascular damage infection gangrene)
Candidiasis
Mucormycosis
Complications screening
I. Nephropathy
a. Urine Albumin/Creatinine ratio Annually
b. If CKD Monitor potassium & CMP
II. Retinopathy
a. Annual eye exam
III. Neuropathy
a. Monofilament, vibration sense with annual foot exam
IV. Diabetic foot risk
a. Current or previous ulcer/amputation = @ Risk
b. Absent pulses +/- claudication (PAD) = @ Risk
c. Annual foot exam
V. Cardiovascular disease (CVD)
a. Chest pain, SOB
b. HTN Ischemic Heart Disease
3
Oral agents
Class Agent Action Contraindication
Biguanides Metformin Increase sensitivity CKD
by increasing Acidosis
peripheral glucose Alcohol abuse
uptake CCF
Sulphonylurias Glimeperide Stimulate insulin Severe liver or renal
release from B cells disease
Incretins Exenetide Stimulate B cells to Do not use with
Glucagon-like produce more DPP-4 inhibitors
peptide 1 (GLP-1) insulin
Inject Pancreatitis or
Slows gastric history thereof
emptying
Dipeptidyl Vildagliptin Inhibit DPP-4 History of
Peptidase (DPP) 4 enzyme blocking pancreatitis
inhibitors inactivation of
incretin hormones Do not use with
GLP-1
Meglitinides Repaglinide Post-prandial
Nataglinide glucose regulator
Alpha glucosidase Acarbose Slows digestion
inhibitors
4
DM treatment (2012 guidelines)
Glucose
Type 2 DM
1. Start Metformin then titrate up to max dose 850 mg
2. ADD: Glimepiride then titrate up
3. ADD: Intermediate acting insulin @ night, start 10U then titrate up based on
morning fasting glucose methods (keep oral agents)
a. If > 20-30U needed then change to biphasic (mixed) insulin 2/3 (70%) in
morning and 1/3 (30%) at night @ 0.3U/kg
b. Start biphasic immediately rather than nocte bolus if:
i. HbA1c > 10%
c. Keep on metformin, stop SU (glimepiride)
Type 1 DM
1. Start basal bolus insulin 0.7 - 0.9U/kg
a. 40% basal at night (intermediate/long acting)
b. 60% bolus divided pre-meal (rapid acting/short acting)
5
c. Patients must have glucose meters
Hypertension
ACE-I +/- CCB +/- Diuretic
Enalapril, amlodipine, HCTZ
High LDL cholesterol
LDL > 1.8 BUT < 3 Simvastatin 10mg
LDL > 3 BUT < 3.5 20mg
LDL > 3.4 But < 4 Atorva 40mg
LDL > 4mg Atorva 80mg
NB 6% rule (double dose reduced LDL with 6% only)
DM control and risk factor control (2012)
Glucose
6
FPG PPG HbA1c
Majority 4.0 - 7.0 5.0 - 10.0 < 7%
Elderly 4.0 - 7.0 < 12.0 < 7.5%
High risk
Test HbA1c 1-2x a year
LDL cholesterol
Test Lipogram 1x a year and follow-up LDL 1-2x a year
LDL < 1.8
BP
BP < 140/90 mmHg unless nephropathy (then lower)