1. DIABETES MELLITUS THOMAS MILLIGAN, DO OSU-COM FAMILY MEDICINE

2. Introduction Types of DM Types of DM Diagnosis Diagnosis Management Management Follow-up Follow-up Complications Complications

3. TYPES Type 1 Type 1 Type 2 Type 2

4. TYPE 1 Pathophysiology Pathophysiology Diagnosis Diagnosis Management Management

5. DIAGNOSIS Random BS of 200 plus symptoms Random BS of 200 plus symptoms –Polyuria –Polydipsia –Unexplained weight loss Fasting BS 126 or Greater Fasting BS 126 or Greater –NPO at Least 8 Hours BS of 200, 2 Hours After 75g Glucose Challenge BS of 200, 2 Hours After 75g Glucose Challenge

6. MANAGEMENT Diet Diet –Decrease Glucose –Pt Must Not Skip Meals Exercise Exercise Insulin Insulin

7. PATHOPHYSIOLOGY Immune related destruction of insulin producing cells Immune related destruction of insulin producing cells Loss of insulin Loss of insulin Insulin required to prevent DKA Insulin required to prevent DKA

8. INSULIN Begin with 20 - 40 u day Begin with 20 - 40 u day –2/3 am, 1/3 pm –Am 2/3 inter, 1/3 regular –Pm 1/2 inter, 1/2 regular Timing Timing –Must be given with respect to meals

9. INSULIN Adjustments Adjustments –Average of 35 - 50 u day 0.6 - 1.2 u/kg/day 0.6 - 1.2 u/kg/day –Maintain FSBS 100 - 250 –Pt keeps log of FSBS to avoid hypoglycemia Intermediate insulin Intermediate insulin –Change evening dose first –Beware of nocturnal hypoglycemia

10. INSULIN Regular insulin Regular insulin –Guided by pre-prandial FSBS –Avoid regular insulin at bedtime –More diet and activity sensitive Multiple Daily Injections (MDI) Multiple Daily Injections (MDI) –Better control –Very compliant pts

11. INSULIN ONSET PEAK DUR ONSET PEAK DUR –LISPRO 15 - 30 m 1 - 3 h 3 - 6 h –REGULAR 15 - 60 m 2 - 6 h 4 - 12 h –NPH 1.5 - 4 h 6 - 16 h 14 -28 h –LENTE 1 - 4 h 6 - 16 h 14 -28 h

12. TYPE 2 Pathophysiology Pathophysiology Diagnosis Diagnosis Management Management

13. PATHOPHYSIOLOGY Usually after age 30 Usually after age 30 Usually obese Usually obese Insulin resistance Insulin resistance Insulin may be used, but not essential Insulin may be used, but not essential Non ketotic hyperosmolar syndrome, not DKA Non ketotic hyperosmolar syndrome, not DKA

14. DIAGNOSIS Random bs of 200 plus symptoms Random bs of 200 plus symptoms –Polyuria –Polydipsia –Unexplained weight loss Fasting BS 126 or greater Fasting BS 126 or greater –NPO at least 8 hours BS of 200, 2 hours after 75g challenge BS of 200, 2 hours after 75g challenge

15. MANAGEMENT Diet Diet Exercise Exercise Oral agents Oral agents Combination Combination Insulin Insulin

16. ORAL AGENTS Sulfonylureas Sulfonylureas Metformin Metformin Troglitazone Troglitazone Acarbose Acarbose

17. SULFONYLUREAS Diabinese, glucotrol, diabeta, micronase, prandin, amaryl Diabinese, glucotrol, diabeta, micronase, prandin, amaryl Increases insulin production Increases insulin production Hypoglycemia Hypoglycemia

18. METFORMIN Glucophage Glucophage Decreases hepatic glucose production Decreases hepatic glucose production No hypoglycemia No hypoglycemia

19. TROGLITAZONE Rezulin Rezulin Increases peripheral glucose uptake Increases peripheral glucose uptake No hypoglycemia if used alone No hypoglycemia if used alone Initial indication is for pts on insulin Initial indication is for pts on insulin Liver toxicity Liver toxicity

20. ACARBOSE Precose Precose Alpha-glucosidase inhibitor Alpha-glucosidase inhibitor Decreases glucose uptake in the gut Decreases glucose uptake in the gut GI intolerance GI intolerance No hypoglycemia No hypoglycemia

21. COMBINATION Use one from each class Use one from each class Reduce dose of other drugs by 1/2 if adding a sulfonylurea Reduce dose of other drugs by 1/2 if adding a sulfonylurea

22. INSULIN Max out oral agents Max out oral agents Start with intermediate acting insulin Start with intermediate acting insulin Eventually will use one modality Eventually will use one modality

23. EVERY VISIT FSBS FSBS UA with microalbumin UA with microalbumin Foot exam, including neuro Foot exam, including neuro

24. EVERY 3 MONTHS HGB A1C HGB A1C

25. EVERY 6 MONTHS Lipids Lipids CHEM 8 CHEM 8

26. YEARLY Ophthomology consult Ophthomology consult EKG EKG

27. COMPLICATIONS Retinopathy, neuropathy, cad, nephropathy, enteropathy, poor wound healing, impotence, depression Retinopathy, neuropathy, cad, nephropathy, enteropathy, poor wound healing, impotence, depression Hyperglycemia is better than no glycemia Hyperglycemia is better than no glycemia