Diabetes Mellitus

Diabetes Mellitus-

-Diabetes Mellitus Type I-

-DM Type IA is caused by autoimmune destruction of the insulin producing beta cells of the Islet of Langerhans
-DM Type IIB is just non autoimmune destruction of the insulin producing beta cells of the Islet of Langerhans
-it is a matter of insulin not being produced instead of our bodies not being able to utilize the insulin the body produces
-DM Type I is best managed with a long acting insulin such as Lantus to take manage basal needs and immediate acting to manage short term needs
-Typically presents with polydipsia, polyuria, and weightless with hyperglycemia and ketonuria
-May be asymptomatic
-Can present with Diabetic Ketoacidosis.  Present with similar symptoms but with drowsiness, fruity smelling breath, and tachypnea, with vomiting.


-To diagnosis Diabetes, fasting glucose of >126, random glucose >200, post prandial glucose of >200 after two hours, or a Hgb A1C of >6.5%.

-Other causes of hyperglycemia include:  critically ill patients (shock or sepsis), medications, and neonatal hyperglycemia (from stress, sepsis and drugs)

-Patients with diabetes need to be screened for complications-

-Patients need annual eye exams to screen for refractive errors, cataracts, glaucoma, and retinopathy

-Foot examination should be inspected at each routine visit to identify problems with nail care, poor fitting footwear, fungal infections, and to screen for neurologic and vascular disease
-Neuropathy and vascular complications put the patient at risk for ulcers which can cause infections and lead to amputations

-Measurement of urinary albumin excretion.  Abnormal results should be repeated at least 2-3 times over a 3-6 month period because of high rate of false positives.  ACE inhibitors or ARB's help this.  The need for further monitoring after instituting these therapies are not certain

-screening for coronary heart disease.  Clinicians obtain a fasting lipid profile, blood pressure, and smoking history to decrease risk factors.  It is not recommended to perform routine stress tests on asymptomatic diabetic patients.

-patients over 50 staring an exercise program, a resting 12 lead EKG is recommended for screening.

-Goal Hgb A1C is less than 7.  It is obtained with every routine office visit lab screen

-Diabetes Type 2-

-Patients with type 2 diabetes have different degrees of insulin resistance
-Hyperglycemia can impair pancreatic beta cell function and make insulin resistance worse
-Majority of therapies are targeted at either increasing pancreatic beta cell activity or to better utilize the insulin in the body

-Recommended routine screening tests for type 2 diabetics is the same as type 1 diabetes

-Therapy for Type 2 Diabetes includes: dietary modification, exercise, weight reduction and medications
-Lifestyle modifications are the first line in treatment
-Metformin should be the initial anti glycemic agent
-next step should include an oral sulfonylurea or basal insulin
-if this therapy fails intensive insulin should be used
-less well validated therapies include pioglitazone or a GLP agonist
-sulfonylureas can lower glucose by 20 percent but lose their effectiveness over time
-meglitinides are short acting glucose lowering drugs that act like sulfonylureas but are less effective
-Thiazolidinediones (Actos and Avandia) lower glucose by decreasing insulin sensitivity
-DPP Inhibitors-are common second line treatments who patients that do not respond to a sulfonylurea
-Glucagon Like Peptide Agonists (GLP-1)-these are administer subcutaneously. These are add on drugs to patients that are poorly controlled on maximal dose of one or two agents
-Alpha Glucosidase Inhibitors-have additive hypoglycemic effects in the patients receiving diet and already on sulfonylureas, metformin, or insulin therapy