This lecture was conducted during the Nephrology Unit Grand Ground by a Sub-intern under Nephrology Division, Department of Medicine in King Saud University. Nephrology Division is NOT responsible for the content of the presentation for it is intended for learning and /or education purpose only.

Walid Al-Tassan

Diabetes Mellitus : a Metabolic disease characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both  Types: 1) Type 1 diabetes 2) Type 2 diabetes 3) Gestational diabetes 4) Secondary diabetes 4) Secondary diabetes  Complications : - Stroke - Heart attack - Kidney disease - Eye Disease - Nerve Damage

Diabetes Mellitus  Type 1 diabetes - Cells that produce insulin are destroyed - Results in insulin dependence - Commonly detected before 30  Type 2 diabetes - Blood glucose levels rise due to 1) lack of insulin production 2) insufficient insulin action (resistant cells) - Commonly detected after 40 - Eventually leads to β -cell failure (resulting in insulin dependence) Gestational Diabetes 3-5% of pregnant women in the US develop gestational diabetes

Thirst. Passing lots of urine. Malaise. Infections (thrush). Weight loss. Polyphagia. Visual disturbance. Symptoms:

Testing: Fasting Plasma Glucose Test (FPG) - (cheap, fast) *fasting B.G.L mg/dl pre-diabetes *>126 mg/dl diabetes Oral Glucose Tolerance Test (OGTT) *tested for 2 hrs after glucose- rich drink * mg/dl pre- diabetes *>200 mg/dl diabetes HbA1c gives an estimate of the glucose control over 2 – 3 months. In the 2010 American Diabetes Association Standards of Medical Care in Diabetes added the A1c ≥ 48 mmol/mol (≥6.5%) as another criterion for the diagnosis of diabetes

Prevention:  Research studies have found that lifestyle changes can prevent or delay the onset of type 2 diabetes among high- risk adults.  These studies included people with IGT and other high- risk characteristics for developing diabetes.  Lifestyle interventions included diet and moderate-intensity physical activity (such as walking for 2 1/2 hours each week).  In the Diabetes Prevention Program, a large prevention study of people at high risk for diabetes, the development of diabetes was reduced 58% over 3 years.

Treatment: The major components of the treatment of diabetes are: Diet and Exercise A Oral hypoglycaemic therapy B Insulin Therapy C

A. Diet: Dietary treatment should aim at: Ensuring weight control Providing nutritional requirements Allowing good glycaemic control with blood glucose levels as close to normal as possible Correcting any associated blood lipid abnormalities  Physical activity promotes weight reduction and improves insulin sensitivity, thus lowering blood glucose levels.  Together with dietary treatment, a programme of regular physical activity and exercise should be considered for each person. Such a programme must be tailored to the individual’s health status and fitness. Exercise:

B. Oral hypoglycaemic therapy: Classes of oral hypoglycaemic agents: Biguanides. Insulin Secretagogues: o Sulphonylureas o Non-sulphonylureas α-glucosidase inhibitors. Thiazolidinediones (TZDs). Peptide analogs.

B. Oral hypoglycaemic therapy: Used in type 2 DM when conservative therapy fails. Start with one agent (Metformin or Sulfonylurea). If monotherapy fails, use a combination of two agent from different classes. Patients with severe disease often don’t respond adequately, therefore require insulin.

Oral Hypoglycaemic Medications

C. Insulin Therapy: Short-term use:  Acute illness, surgery, stress and emergencies.  Pregnancy.  Breast-feeding.  Insulin may be used as initial therapy in type 2 diabetes in marked hyperglycaemia.  Severe metabolic decompensation (diabetic ketoacidosis, hyperosmolar nonketotic coma, lactic acidosis, severe hypertriglyceridaemia). Long-term use:  If targets have not been reached after optimal dose of combination therapy, consider change to multi-dose insulin therapy.

typeonsetduratio n comments Human insulin Lispro15 min4 hr Regular insulin30-60 min 4-6 hrGiven I.V NPH insulin2-4 hr10-18 hr Ultralente insulin (long standing) 6-10 hr18-24 hr 70/30 mixture30 min10-16 hr70% NPH, 30% regular Glargine3-4 hr24 hrGiven at bedtime

Thank You!