1. Clinical Overview of Diabetes Mellitus Slide share located at: http://ited5blog.blogspot.com/http://ited5blog.blogspot.com/ YouTube (2) (abbreviated audio with PowerPoint located at): http://ited5blog.blogspot.com/http://ited5blog.blogspot.com/ All information on blog, slide share, and YouTube are contained within this PowerPoint. No additional material is present. You should only review slide share and YouTube is this makes your studying more efficient.

2. Objectives 1.Know definitions of: pre-diabetic state, impaired glucose tolerance, and Diabetes Mellitus. 2.Understand etiologies of DM. 3.Understand acute DM complications. 4.Understand chronic DM complications. 5.List the Quality Improvement markers of DM.

3. Format Lecture format. Not a Socratic exchange. Test questions: multiple choice questions with only one correct answer. Testable material: –You will find the crossroads sign ╬ present when the material is testable. –Material not having the crossroads sign is for context: to make the testable material more understandable.

4. Objective one: Know definitions of: pre-diabetic state impaired glucose tolerance Diabetes Mellitus.

5. Objective one: Know definitions of: ╬ pre-diabetic state: fasting plasma glucose of 100 to 125 mg/dL. impaired glucose tolerance Diabetes Mellitus.

6. Objective one: Know definitions of: pre-diabetic state impaired glucose tolerance: ╬ plasma glucose of 140 to 199 mg/dL 2 hours after a 75-g oral glucose load. –Patients with pre-diabetic state or impaired glucose tolerance are at higher risk for the future development of diabetes –Pre-diabetic state or impaired glucose tolerance: more useful to the evaluation of patients with possible type 2 diabetes. patients with type 1 diabetes usually present with more severe hyperglycemia - making identification of DM more straightforward. Diabetes Mellitus.

7. Objective one: Know definitions of: pre-diabetic state impaired glucose tolerance ╬ Diabetes Mellitus: *Fasting plasma glucose ≥ 126 mg/Dl *Casual plasma glucose ≥ 200 mg/Dl (if accompanied by symptoms) *2-hour Plasma Glucose (after 75-g oral glucose load (Oral Glucose Tolerance Test)) ≥ 200 mg/Dl. Adapted from: American Diabetes Association Standards of Medical Care in Diabetes. Diabetes Care. 2005;28:S5-S7.

8. Objective one: Know definitions of: pre-diabetic state impaired glucose tolerance Diabetes Mellitus: »Fasting plasma glucose ≥ 126 mg/Dl »*Casual plasma glucose ≥ 200 mg/Dl ( if accompanied by symptoms) ╬ Symptoms of: polyuria, polydipsia, or blurred vision. This stipulation prevents a diagnosis in patients with transient hyperglycemia (in the setting of an acute illness), although many such patients will be diagnosed with diabetes when properly tested after recovery. Adapted from: American Diabetes Association Standards of Medical Care in Diabetes. Diabetes Care. 2005;28:S5-S7.

9. HbA1c The hemoglobin A1c (HbA1c) is a long-term (2 to 3 months) marker of glucose control. An elevated level is specific for diabetes; however, HbA1c is too insensitive for use as a screening test. Many patients with mild diabetes may still have a normal HbA1c.

10. ╬ Definitions Summary

11. Objectives 1.Know definitions of: pre-diabetic state, impaired glucose tolerance, and Diabetes Mellitus. 2.Understand etiologies of DM I AND DM II.

12. Etiologies of DM Type 1 diabetes mellitus Type 2 diabetes mellitus Gestational diabetes mellitus Other Adapted from: American Diabetes Association Standards of Medical Care in Diabetes. Diabetes Care. 2005;28:S1.

13. Etiologies of DM *Type 1 diabetes mellitus *Beta-cell destruction, usually leading to absolute insulin deficiency *Immune-mediated *Idiopathic Type 2 diabetes mellitus Gestational diabetes mellitus Other specific types – Adapted from: American Diabetes Association Standards of Medical Care in Diabetes. Diabetes Care. 2005;28:S1.

14. Etiologies of DM Type 1 diabetes mellitus *Type 2 diabetes mellitus *Ranging from predominantly insulin resistance with relative insulin deficiency to *a predominantly secretory defect with insulin resistance Gestational diabetes mellitus Other specific types Adapted from: American Diabetes Association Standards of Medical Care in Diabetes. Diabetes Care. 2005;28:S1.

15. Etiologies of DM Type 1 diabetes mellitus Type 2 diabetes mellitus *Gestational diabetes mellitus *Affects about 7% of pregnancies *Pathogenesis similar to Type 2 DM *acute insulin resistance of pregnancy posing too great a stress to the pancreatic beta cells *Initial screen: 1 hour plasma glucose after 50-g oral glucose load (called oral glucose challenge test). *If glucose is >= 140 mg/Dl 1-hour after 50-g oral glucose load = GDM ╬ Test as soon as pregnancy is noted in patients with risks of: marked obesity, glycosuria, history of GDM during prior pregnancies, or family history of diabetes. If neg., repeat at 24 to 28 weeks gestation. It is generally agreed that testing is not required for low-risk patients (age younger than 25 years, normal pre-pregnancy weight, no family history of diabetes, not a member of high-risk ethnic group, and no history of abnormal glucose testing or poor obstetric outcomes). Other specific types Adapted from: American Diabetes Association Standards of Medical Care in Diabetes. Diabetes Care. 2005;28:S1.

16. Possible Test Question: In a pregnant patient, perform glucose challenge test: 1.Six months into pregnancy if risks of marked obesity, glycosuria, history of GDM during prior pregnancies, or family history of diabetes are present. 2.Three months into pregnancy if risks of marked obesity, glycosuria, history of GDM during prior pregnancies, and family history of diabetes are present. 3.As soon as pregnancy is noted, only if the patient has all of the following risks: marked obesity, glycosuria, history of GDM during prior pregnancies, and family history of diabetes. 4.╬ As soon as pregnancy is noted if risks of marked obesity, glycosuria, history of GDM during prior pregnancies, or family history of diabetes are present. (Correct answer). 5.Eight months into pregnancy for all women regardless of risks

17. Etiologies of DM Type 1 diabetes mellitus Type 2 diabetes mellitus Gestational diabetes mellitus Other specific types - I will not ask about these on a test - this is for context. – Genetic defects in beta-cell function, including maturity onset diabetes of the young – Genetic defects in insulin action – Diseases of the exocrine pancreas: pancreatitis, pancreatic cancer, cystic fibrosis, hemochromatosis – Endocrinopathies: Cushing's syndrome, acromegaly, glucagonoma, pheochromocytoma – Drug- or chemical-induced: nicotinic acid, corticosteroids, diazoxide – Infections: cytomegalovirus, congenital rubella – Uncommon forms of immune-mediated diabetes – Other genetic syndromes associated with diabetes (Down's, Turner's, Klinefelter's, Prader-Willi, Laurence-Moon-Biedl, myotonic dystrophy, Huntington's chorea) Adapted from: American Diabetes Association Standards of Medical Care in Diabetes. Diabetes Care. 2005;28:S1.

18. Objectives 1.Know definitions of: pre-diabetic state, impaired glucose tolerance, and Diabetes Mellitus. 2.Understand etiologies of DM. 3.Understand acute DM complications.

19. Objective 3: Understand acute DM complications. DM I: *Diabetic Keto-acidosis and (rarely) associated cerebral edema *Hypoglycemia (from medications): ask your patients if they have hypoglycemic awareness. DMII: *Hyperglycemic hyperosmolar syndrome Plasma osmolality > 300; Serum glucose > 600; normal pH. Often associated with precipitating events: MI, infection, new renal insufficiency. *Hypoglycemia (from medications).

20. Objective 3: Understand acute DM complications. DM I and DMII: Hypoglycemia (from medications). ╬ Symptoms of hypoglycemia: *Personality change *Cognitive impairment *Loss of consciousness *Seizure *Coma *Irreversible brain injury

21. Objectives 1.Know definitions of: pre-diabetic state, impaired glucose tolerance, and Diabetes Mellitus. 2.Understand etiologies of DM. 3.Understand acute DM complications. 4.Understand chronic DM complications.

22. Objective 4: Understand chronic DM complications. Microvascular disease –Diabetic nephropathy –Diabetic retinopathy Peripheral neuropathy Macrovascular disease, involving: –Coronary, carotids, cerebral, aorta, arteries to the legs Leads to: –MI, stroke, gangrene

23. Objective 4: Understand chronic DM complications. Microvascular disease *Diabetic nephropathy: *Period of glomerular hyperfiltration and intraglomerular hypertension. *DM is the most common cause of renal failure world wide. *Abnormal albumen excretion is an early sign. *Aggressive hypertension control, ACE inhibitor therapy, and glucose control can slow progression. –Diabetic retinopathy: Peripheral neuropathy Macrovascular disease

24. Objective 4: Understand chronic DM complications. Microvascular disease –Diabetic nephropathy *Diabetic retinopathy: *DM is the cause of most legal blindness in US. *Background diabetic retinopathy: *Hard exudates, microaneurisms, minor hemorrhages *Proliferative retinopathy: *Neovascularization *Significant retinal hemorrhage *Macular edema *Cotton wool spots - indicate retinal infarcts Peripheral neuropathy Macrovascular disease

25. International Clinical Diabetic Retinopathy Disease Severity Scale

26. Objective 4: Understand chronic DM complications. Microvascular disease –Diabetic nephropathy –Diabetic retinopathy: *Peripheral neuropathy: *Stocking glove distribution *Paresthesias or painful dysthesia *Mononeuropathies: radiculopathy, cranial nerve peripheral nerve (Less common) Autonomic neuropathy: Orthostatic hypotension, erectile dysfunction, gastroparesis, diabetic diarrhea, atonic bladder Cardiac: loss of physiological cardiac response to physiological stimuli (valsalva, standing, deep breathing) Macrovascular disease, involving: –Coronary, carotids, cerebral, aorta, arteries to the legs Leads to: –MI, stroke, gangrene

27. Objective 4: Understand chronic DM complications. Microvascular disease –Diabetic nephropathy –Diabetic retinopathy: Peripheral neuropathy *Autonomic neuropathy: *Orthostatic hypotension, *erectile dysfunction, *gastroparesis, *diabetic diarrhea, *atonic bladder *Cardiac: *loss of physiological cardiac response to physiological stimuli (valsalva, standing, deep breathing) Macrovascular disease, involving: –Coronary, carotids, cerebral, aorta, arteries to the legs Leads to: –MI, stroke, gangrene

28. Objective 4: Understand chronic DM complications. Microvascular disease –Diabetic nephropathy –Diabetic retinopathy: Peripheral neuropathy Autonomic Neuropathy *Macrovascular disease, involving: *Coronary, carotids, *cerebral, *aorta, *arteries to the legs *Leads to: MI DM is associated with 2 to 4 fold increase in risk of MI (associated with hyperlipidemia and hypertension; controlling glucose does not help) ╬ Keep: BP < 130/80; LDL < 100. stroke, gangrene

29. Objective 4: Understand chronic DM complications. Microvascular disease –Diabetic nephropathy –Diabetic retinopathy: Peripheral neuropathy: Macrovascular disease, involving: –Coronary, carotids, cerebral, aorta, arteries to the legs *OTHER COMPLICATIONS: –Impaired wound healing –Increased post operative infection –Sleep apnea (related to obesity) –Venous thrombosis –Osteoporosis –Dementia –Depression –Cancers: colorectal carcinoma, endometial carcinoma Cause is not known; mitogenic effects of insulin in hyperinsulinemic patients is suspected.

30. Objectives 1.Know definitions of: pre-diabetic state, impaired glucose tolerance, and Diabetes Mellitus. 2.Understand etiologies of DM. 3.Understand acute DM complications. 4.Understand chronic DM complications. 5.List the Quality Improvement markers of DM.

31. Objective 5: List the Quality Improvement markers of DM Quality Improvement: a movement to better the health of patients. Currently two commonly used markers in QI programs: DM, and HTN. Quality Improvement is measured at the individual physician, clinic, system, and state levels. Quality Improvement programs are tied to reimbursement.

32. Objective 5: List the Quality Improvement markers of DM Markers: 1.╬ BP < 130 systolic 2.╬ LDL < 100 3.Annual monofilament test for peripheral neuropathy. 4.Annual dilated eye exam. 5.Test for microalbuminuria. 6.Use of ACE inhibitors if albumen present 7.Hgb A1c < 7 These markers will be public data by the time you practice. Physicians are currently reimbursed based upon their Quality Improvement numbers in some systems.

33. Objective 5: List the Quality Improvement markers of DM Markers: ╬ BP < 130 systolic, ╬ LDL < 100, Annual monofilament test for peripheral neuropathy, Annual dilated eye exam, Test for microalbuminuria, Use of ACE inhibitors if albumen present, Hgb A1c < 7. These markers will be public data by the time you practice. Physicians are currently reimbursed based upon their Quality Improvement numbers in some systems. *The reimbursement and “counting” is usually based upon various groupings. *I.e. If you have 30% of your patients meeting criteria 1 to 4, you get counted as being “good.” *If you have 7.5% of patients meeting criteria 1 to 7, you are counted.

34. Objectives 1.Know definitions of: pre-diabetic state, impaired glucose tolerance, and Diabetes Mellitus. 2.Understand etiologies of DM. 3.Understand acute DM complications. 4.Understand chronic DM complications. 5.List the Quality Improvement markers of DM.

35. 1. Know definitions of: ╬ pre-diabetic state: fasting plasma glucose of 100 to 125. ╬ impaired glucose tolerance: plasma glucose of 140 to 199 2 hours after a 75-g oral glucose load. ╬ DM: Fasting glucose ≥ 126; Casual plasma glucose ≥ 200 (if accompanied by symptoms (polyuria, polydipsia, or blurred vision); 2-hour Plasma Glucose (after 75-g oral glucose load) ≥ 200. 2.Understand etiologies of DM. Perform glucose challenge test as soon as pregnancy is noted in patients with risks of: ╬ marked obesity, glycosuria, history of GDM during prior pregnancies, or family history of diabetes. 3.Understand acute DM complications. ╬ Symptoms of hypoglycemia:Personality change,Cognitive impairment, Loss of consciousness, Seizure, Coma, Irreversible brain injury 4.Understand chronic DM complications. Macrovascular disease. DM is associated with 2 to 4 fold increase in risk of MI (associated with hyperlipidemia and hypertension. ╬ Keep BP < 130 systolic; Keep LDL < 100. 5.List the Quality Improvement markers of DM. ╬ BP < 130 systolic ╬ LDL < 100 ∑

36. Possible Test Question: In a pregnant patient, perform glucose challenge test: 1.Six months into pregnancy if risks of marked obesity, glycosuria, history of GDM during prior pregnancies, or family history of diabetes are present. 2.Three months into pregnancy if risks of marked obesity, glycosuria, history of GDM during prior pregnancies, and family history of diabetes are present. 3.As soon as pregnancy is noted, only if the patient has all of the following risks: marked obesity, glycosuria, history of GDM during prior pregnancies, and family history of diabetes. 4.╬ As soon as pregnancy is noted if risks of marked obesity, glycosuria, history of GDM during prior pregnancies, or family history of diabetes are present. (Correct answer). 5.Eight months into pregnancy for all women regardless of risks