HIHIM Clinical Cocepts for Managers

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Katherine Heath
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1 Fernando Vega, MD HIHIM Hyperglycemia characterized by relative or absolute lack of insulin secretion Varying degrees of insulin resistance Often associated with symptoms: polyruia, polydipsia, unexplained weight loss 2 Insulin Enhances peripheral glucose uptake Inhibits breakdown of liver glycogen Enhances storage of glucose as glycogen Increases protein synthesis Increases triglyceride storage Normal fasting glucose < 100 Normal postprandial glucose < Fasting 2 hours pp Another definition Normal < 100 < 140 IFG IGT Hemoglobin A1c equal or greater than 6.5% (Adopted by the American Diabetes Association in 2010) Diabetes > 126 > Fernando Vega, MD 1

2 Classification of Diabetes Type 1 Destruction of pancreatic beta cells leading to absolute insulin deficiency Type 2 Variable degrees of insulin deficiency and resistance Terminology Gestational diabetes Diabetes secondary to other conditions The majority diabetes seen is Type 2 The majority of Type 2 diabetics have no awareness of their disease at the time of diagnosis The majority of Type 2 diabetics Are estimated to go undiagnosed or untreated for months and years Have more insulin than the average person 7 8 Type 1 diabetes Juvenille (usually) Abrupt onset Family history Autoimmune Ketones Total insulin def, Islet cell AB pos HLA DR3 DR4 Insulin dependent Type 2 diabetes Older age (usually) Slow onset Family history Not autoimmune No ketones Partial Insulin deficiency, resistance Insulin requiring Diet influenced Secondary Diabetes Steroids Thiazide Diuretics Drugs for HIV Pancreatectomy Acute pancreatitis Chronic Pancreatitis Haemachromatosis Cystic Fibrosis Cushings Disease Acromegaly MODY DIDMOAD 9 10 Prevalence: 7% of the US population has diabetes ½ of them are undiagnosed The prevalence is increasing Typical presentations: Patient with diabetic symptoms Polyuria, polydipsia, weight loss, fatigue Sleepiness, coma Patient with another illness that precipitates a diabetic crisis Patient with discovery on routine screening Fernando Vega, MD 2

3 Clinical Management Acutely In office Inpatient Assessment of progression Clinical Management Long Term Glycemic control Diet, excercise Oral hypoglycemics y Insulin Blood pressure control Lipid control Preventing, Monitoring complications Treatments for Hyperglycemia Other treatments Diet Metformin Sulphonylureas Acarbose Thiazolidinediones Netaglinide/Repag. Regular Insulin Long acting Insulin Analogue insulins Mixed insulins Anti-hypertensives Statins/fibrates Aspirin ACE inhibitors ARBs Treat to Target HbA1C < 7% BP < 135/80 Cholesterol <5 mmol/l HDL-C >1mmol/l Triglycerides <1.5mmol/l Clinical Course of Diabetes Immediate consequences Early consequences Late consequences Fernando Vega, MD 3

4 Clinical Course of Diabetes - Early consequences Tendency to yeast infections Clinical Course of Diabetes - Immediate consequences Visual blurring Hypoglycemic episodes Weight changes Clinical Course of Diabetes - Late consequences Microvascular Disease: Nephropathy Retinopathy Atherosclerosis Coronary artery Peripheral Vascular Disease Peripheral Neurop Femoral Amyotrophy Mononeuritis multiplex Autonomic Postural hypotension Diarrhoea Impotence Atonic bladder Sweating Loss of hypo. awarenes Nephropathy Retinopathy Diabetic glomerulosclerosis Microalbuminuria <300mg/l Proteinuria >300mg/l Nephrotic >3g/l Abnormal creatinine Glycaemic control BP control CAPD Transplantation Background DR Pre-proliferative DR Proliferative DR Maculopathy Fluroscein angiography Laser Blood Pressure Lipids Glucose Fernando Vega, MD 4

5 Vascular Disease in Diabetes Coronary Artery Disease Peripheral Vascular Disease Cerebrovascular Disease Coronary Artery Disease Angina MI Silent infarct CCF ECG Cardiac enzymes Troponin I Exercise stress test Echocardiography Angiography Angioplasty/CABG Cerebrovascular Disease Peripheral Vascular Disease TIAs CVAs Dementia CT scan Carotid Dopplers Treat risk factors Carotid bypass surgery Intermittent Claudication Cold Legs Pulseless Leg Foot Ulcers Gangrene Doppler Studies Duplex Scanning Angiography Angioplasty Treat risk factors Diabetic Foot PVD Charcot Arthropathy Ulceration MRI Angiography Clinical Management Anticipatory prevention Evaluation of Diabetic Complications Routine Eye exams Routine Foot exams Screening for microalbuminuria Screening for atherosclerosis / coronary heart disease Fernando Vega, MD 5

6 Clinical Management Anticipatory prevention Reducing the risk for microvascular Disease Smoking cessation Aspririn Blood pressure control Dyslipidemia Clinical Management Management of Complications Coronary Artery Disease - silent MI s require more vigilance Kidney disease - Prevention is the mainstay of treatment Eye disease diabetic retinopathy Economic/Social facts 1:14 adults By 2025 more people 1: worldwide will have 1:5 >75 diabetes than now live in N.America 1:3 Unaware of diagnosis 2-4 fold greater risk of Type 1 Life 20yrs less stroke and heart Type 2 Life 10yrs less disease 65% of deaths from CVS disease 33 Fernando Vega, MD 6

TYPE 2 DIABETES MELLITUS: NEW HOPE FOR PREVENTION. Robert Dobbins, M.D. Ph.D.

TYPE 2 DIABETES MELLITUS: NEW HOPE FOR PREVENTION Robert Dobbins, M.D. Ph.D. Learning Objectives Recognize current trends in the prevalence of type 2 diabetes. Learn differences between type 1 and type