DIABETES MELLITUS THOMAS MILLIGAN, DO OSU-COM FAMILY MEDICINE

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

TYPES Type 1 Type 1 Type 2 Type 2

TYPE 1 Pathophysiology Pathophysiology Diagnosis Diagnosis Management Management

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

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

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

INSULIN Begin with u day Begin with 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

INSULIN Adjustments Adjustments –Average of u day u/kg/day u/kg/day –Maintain FSBS –Pt keeps log of FSBS to avoid hypoglycemia Intermediate insulin Intermediate insulin –Change evening dose first –Beware of nocturnal hypoglycemia

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

INSULIN ONSET PEAK DUR ONSET PEAK DUR –LISPRO m h h –REGULAR m h h –NPH h h h –LENTE h h h

TYPE 2 Pathophysiology Pathophysiology Diagnosis Diagnosis Management Management

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

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

MANAGEMENT Diet Diet Exercise Exercise Oral agents Oral agents Combination Combination Insulin Insulin

ORAL AGENTS Sulfonylureas Sulfonylureas Metformin Metformin Troglitazone Troglitazone Acarbose Acarbose

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

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

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

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

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

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

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

EVERY 3 MONTHS HGB A1C HGB A1C

EVERY 6 MONTHS Lipids Lipids CHEM 8 CHEM 8

YEARLY Ophthomology consult Ophthomology consult EKG EKG

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