1. DIABETES MELLITUS SALMA AHI MD,ENDOCRINOLOGIST JANUARY2015

2.  DM1 OR 2 AGENDA  WHO SHOULD SCREEN  DIAGNOSTIC CRITERIA  DIABETES MANAGEMENT DRUG TREATMENT  DIABETES COMPLICATIONS HLP CAD RETINOPATHY NEPHROPATHY NEUROPATHY DIABETIC FOOT  CASE MANAGEMENT

3. DM1OR DM2  Obese or Thin  Old or Young [LADA,MODY,YOUTHS,GDM,CF,HIV]  FH  Ketosis [DKA OF DM1, KETOSIS PRONE DM2]

14.  SMBG results may help guide treatment decisions and/or self-management for patients using less frequent insulin injections or noninsulin therapies  When prescribing SMBG, ensure that patients receive ongoing instruction and regular evaluation of SMBG technique, SMBG results, and their ability to use SMBG data to adjust therapy

16. CORONARY HEART DISEASE Recommendations Screening In asymptomatic patients, routine screening for coronary artery disease(CAD) is not recommended because it does not improve outcomes as long as CVD risk factors are treated. A

17. RETINOPATHY Recommendations Optimize glycemic control to reduce the risk or slow the progression of retinopathy. A Optimize blood pressure control to reduce the risk or slow the progression of retinopathy. A Screening Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onsetof diabetes. B Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist shortly after the diagnosis of diabetes. B

18. NEPHROPATHY Recommendations Optimize glucose control to reduce the risk or slow the progression of diabetic kidney disease. A Optimize blood pressure control to reduce the risk or slow the progression of diabetic kidney disease. A At least once a year, assess urinary albumin [UACR]) and estimated glomerular filtration rate (eGFR) in patients with type 1 diabetes duration of5 years and in all patients with type 2 diabetes. B

19. HYPERTENSION/BLOOD PRESSURE CONTROL Recommendations Screening and Diagnosis Blood pressure should be measured at every routine visit. Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day. B

21. 21 Nylon monofilament test There is a risk of ulcer formation if the patient is unable to feel the monofilament when it is pressed against the foot with just enough pressure to bend the filament. The patient is asked to say "yes" each time he or she feels the filament. Failure to feel the filament at four of 10 sites is 97 percent sensitive and 83 percent specific for identifying loss of protective sensation. One study found that failure to detect pressure from this monofilament at any of 12 places on the foot (figure) was the single most practical measurement of risk assessment. "Loss Of Protective Sensation (LOPS)" = Lack of perception at 4 out of 10 test sites on foot

22. 22 Diffuse neuropathies Focal neropathies DSPN Large fiber neropathy Small fiber neuropathy Proximal motor neuropathy Acute mononeurop athies Entrapment syndromes Sensory loss 0-++++ (touch, vibration) 0-± (thermal, allodynia) 0-+0-±+-++± pain+-++±+-++±+-++±+-++±+-± Tendon reflex N-↓↓↓N-↓N-↓↓NN Motor deficit 0-+++0+-++±+-++++-++± Different clinical presentations of diabetic neuropathies

23. 23 Large fiber neropathy Small fiber neuropathy Impaired vibration perception Impaired position sense Symptoms predominant Associated with allodynia Defective warmth sensation Defective autonomic function: Decreased sweating,dry skin,impaired vasomotion and blood flow, a cold foot Reduced sensitivity to 1.0-g Semmes Weistein monofilament Depressed tendon reflexes Remarkable intactness of reflexes Deep-seated gnawing,dull,toothache-like in the bones of the feet, or even crushing or cramp-like pain Superficial,burning pain Sensory ataxia(wadeling gait) Electrophysiologically silent Wasting of small muscle of feet : hammer toes(intrinsic minus feet and hand) with weakness of hands and feet Shortening of Achilles tendon: pes equinus Risk of charcot´s neuropathy Foot ulceration and subsequent gangrene

24. 24 DM Neuropathy Motor n.Sensory n. Autonomic n. Intrinsic muscle wasting Abnormal machanics of foot muscles Abnormal pressure on foot Multiple minor painless Fx. Recurrent subluxation Charcot joint Decreased pain and position sensation Sympathetic dysfunction Denervation of vessels Drying of the skin Fissure formation Increased foot circulation (Hyperthermia) Distended pedal veins Increased bone resorption Pounding pulses (A red and warm foot) Structural changes in the foot(hammer toe/claw toe appearance, prominent metatarsal heads) Anhydrosis

31. Case 1: A 73-year-old woman, living alone, who was diagnosed approximately 20 years ago with type T2DM. She has a history of congestive heart failure, but she remains active and is completely independent. She is not overweight and her blood pressure is within the normal range. Her HbA1c has been running between 5.5-6 She had several episodes of hypoglycemia every day

32. Her current diabetes medications Insulin NPH of 22 units in the morning and 16 units in the evening. Metformin 1g twice a day Glibenclamide 5 mg twice a day. Furosemide and Lisinopril for her heart failure. FBS:260 She had got dizzy and fallen one week ago, she had a snack, and then she was fine. She had this problem a couple of times before that.

33. Her main problems? Long-standing T2DM A history of heart failure Episodes of recurrent falls Estimated glomerular filtration rate or "eGFR is 45

34. Which of the following treatment goals do you believe are most important for this patient? 1- Current level of glycemic control and occasional hypoglycemic events are acceptable 2- Prevent further hypoglycemic events and accept a higher HbA1c of ~9% 3- Reduce the HbA1c to <7% and accept some hypoglycemic events 4- Prevent further hypoglycemic events and reduce the HbA1c to ~8%

35. With respect to the patient's oral medications, what course of action do you think would be appropriate at this time? 1- Continue both the Metformin and Sulfonylurea 2- Discontinue Metformin, continue the Sulfonylurea 3- Discontinue the Sulfonylurea, continue Metformin 4- Discontinue both the Metformin and Sulfonylurea

36. Case 2: A 17 years old boy was diagnosed with type ? diabetes approximately 8 months ago. He was very healthy and very active before it. He currently uses Glibenclamide 30 mg to manage his diabetes but, after several months, his blood glucose is steadily increasing. He recently had to abuse her mother insulin to control his hyperglycemia FBS:760 when experienced a ketoacidotic episode. The patient and his mother are now visiting you one week after his hospital visit. HbA1c has been higher at his last couple of visits, and currently it's almost 13 per cent.

37. How concerned would you be about the patient's level of glycemic control? 1- I would not be concerned at this point 2- This is not unusual, but I would still be concerned 3- This is unusual, and I would be concerned 4- I would be very concerned

38. What of the following therapeutic approaches would you most likely favor in this patient? 1- Encourage him to continue with OHA 2- Switch to premixed insulin 3-Switch to basal insulin plus rapid acting insulin 4-Switch to NPH insulin plus Regular insulin

39. What would be a reasonable HbA1c target for this patient over the next 3-6 months? 1- <8% 2- <7.5% 3- <7.0% 4- <6.5%