4. HISTORY OF PRESENT ILLNESS
1day PTC
Body malaise and fatigue
-hgt level of18.7 mmol/L
Hrs PTC
⢠random checking hgt-
19.7 mmol/L
Persistence of symptoms-
Consultation
5. PAST MEDICAL HISTORY
⢠DM x 19 years (Glucovance 500mg/ 2.5 mg OD)
⢠HPN x 27years (unrecalled meds; poor compliance)
⢠(-) stroke
⢠(-) BA
⢠(-) kidney disease
⢠(-) thyroid disease
6. PERSONAL AND SOCIAL HISTORY
⢠College Graduate
⢠Retired government employee
12. PHYSICAL EXAMINATION
⢠General
⢠conscious, coherent, and cooperative, not in respiratory distress
⢠Vital Signs:
⢠Blood Pressure: 170/90 mmHg
⢠Cardiac Rate: 89 bpm
⢠Respiratory Rate: 20 cpm
⢠Temperature: 36.9 º C
⢠Weight: 187 lbs
⢠Height- 5â3
⢠BMI= 33.9 kg/cm2 (obese)
13. ⢠Skin:
⢠I â Fair; hyperpigmented macules over the upper and lower
extremities
⢠P â Moist and warm to touch
⢠Head: I- Normocephalic, black; no chloasma
⢠Eyes: pink palpebral conjunctiva, Sclera white, Pupils equally round,
opaque lens, OD
⢠Nose and Sinuses: nasal mucosa pink, septum midline, tenderness
upon palpation of frontal sinuses
14. ⢠Mouth & Throat: Oral mucosa pink; tongue midline, dry; pharynx
without exudates; tonsils not enlarged
⢠Neck- (-) mass, supple, trachea midline, thyroid gland not enlarged,
no palpable lymph nodes
⢠Chest: symmetrical, (-) no lesions nor scars; Equal bilateral chest
expansion, Resonant on percussion, clear breath sounds
15. ⢠Cardiovascular: AP, NCRR, (-) heaves or thrills, (-) murmur
⢠Breast: symmetric, no palpable masses, (-) tenderness
⢠Gastrointestinal: Flabby, NABS (10 BS/minute), (-) dullness, nontender
⢠Extremities: (-) edema, (-) pallor, warm, (+) clammy, CRT <2 secs
⢠Musculoskeletal: (-) deformities; fair range of motion on all joints
⢠Neurological Exam
⢠Mental status: Alert; thought coherent; oriented to person, place & time;
⢠Cerebellar: slow alternating movements, point-to-point movements intact
⢠Sensory: pinprick, light touch, position sense, vibration sense intact
18. SALIENT FEATURES
Pertinent History Pertinent Physical Examination
Fatigue
Body weakness
Hgt monitoring level of 18-19.7 mmol/L
History of diabetes x 19 years
History of hypertension, poorly controlled
69 years old
BP of 170/90 mmHg
BMI of 33.9 kg/cm2
opaque lens, OD
Clammy skin
21. DIABETES MELLITUS
⢠chronic disease
⢠pancreas does not produce enough insulin, or when the body cannot
effectively use the insulin it produces ď increased concentration of
glucose in the blood (hyperglycemia). (WHO, 2014)
⢠group of common metabolic disorders that share the phenotype of
hyperglycemia.
⢠Reduced insulin secretion, decreased glucose utilization, and
increased glucose production (Harrisons, 2012)
22. PREVALENCE
ďˇ U.S.
Diagnosed: 26 million peopleâ8.3% of
population (90%+ have Type 2)
79 million people have pre-diabetes
CDC 2011
23. PREVALENCE
ďˇ Philippines
- 1 out of every 5 Filipinos have diabetes
- Children as young as 5-years old have been
diagnosed with type 2 diabetes
- - Over 7 million Filipinos will have diabetes by
2030
Philippine Diabetes Statistics,2012
24. CLASSIFICATION
⢠Type 1 diabetes mellitus
⢠from auto-immune beta-cell destruction, leading to absolute insulin deficiency.
Typically but not exclusively in children
⢠Type 2 diabetes mellitus
⢠from a progressive insulin secretory defect on the background of insulin
resistance
⢠Gestational diabetes mellitus (GDM)
⢠Secondary diabetes
33. CRITERIA FOR THE DIAGNOSIS OF DIABETES
ďą A1C > 6.5%
or
ďą FPG > 126 mg/dl (7.0 mmol/l)
or
ďą 2-h plasma glucose > 200 mg/dl (11.1 mmol/l) during an OGTT
or
ďą Random plasma glucose >200 mg/dl (11.1 mmol/l) + classic symptoms
of hyperglycemia
34. CATEGORIES OF INCREASED RISK FOR DIABETES
(PREDIABETES)
ď Impaired fasting glucose (IFG) - FPG levels 100â125 mg/dl
[5.6â6.9 mmol/l]
Or
ď Impaired glucose tolerance (IGT) - 2-h PG values in the OGTT
of 140 â199 mg/dl [7.8 â11.0 mmol/l]
Or
ď A1C 5.7â6.4%
35. SHOULD UNIVERSAL SCREENING BE DONE AND
HOW SHOULD SCREENING BE DONE?
⢠All individuals being seen at any physicianâs clinic or by any
healthcare provider should be evaluated annually for risk factors for
type 2 diabetes and pre-diabetes.
⢠Universal screening using laboratory tests is not recommended as it
would identify very few individuals who are at risk.
36. DEMOGRAPHIC AND CLINICAL RISK FACTORS FOR TYPE 2 DM
⢠Testing should be considered in all
adults > 40 yo
⢠Consider earlier testing if with at least one
other risk factor as follows:
⢠History of IGT or IFG
⢠History of GDM or delivery of a baby
weighing 8 lbs or above
⢠Polycystic ovary syndrome (PCOS)
⢠Overweight: Body Mass Index (BMI)2 of
> 23 kg/m2 or
⢠Obese: BMI of > 25 kg/m2 ,or
⢠Waist circumference > 80 cm
(females) and > 90 cm (males), or
⢠Waist-hip ratio (WHR) of > 1 for males
and > 0.85 for females
⢠First degree relative with Type 2
diabetes
⢠Sedentary lifestyle
⢠Hypertension (BP > 140/90 mm Hg)
⢠Diagnosis or history of any vascular
diseases including stroke, peripheral
arterial occlusive disease, coronary
artery disease
⢠Acanthosis nigricans
⢠Schizophrenia
⢠Serum HDL < 35 mg/dL (0.9 mmol/L)
and/or
⢠Serum Triglycerides > 250 mg/dL (2.82
mmol/L)
37. SCREENING FOR AND DIAGNOSIS OF GDM
ďś Perform a 75-g OGTT, with plasma glucose measurement fasting
and at 1 and 2 h, at 24â28 weeks of gestation in women not
previously diagnosed with overt diabetes.
ďś Performed in the morning after an overnight fast of at least 8 h.
ďś The diagnosis is made when any of the following plasma glucose
values are exceeded:
⢠Fasting 92 mg/dl (5.1 mmol/l)
⢠1 h 180 mg/dl (10.0 mmol/l)
⢠2 h 153 mg/dl (8.5 mmol/l)
38. GLUCOSE MONITORING
ďˇ Patients on multiple-dose insulin (MDI) or insulin pump therapy
should do self-monitoring of blood glucose (SMBG):
⢠prior to meals and snacks
⢠postprandial
⢠at bedtime
⢠prior to exercise
⢠when they suspect low blood glucose
⢠after treating low blood glucose until they are normoglycemic
⢠prior to critical tasks such as driving.
39. A1C MONITORING
⢠at least two times a year - patients who are
meeting treatment goals/ stable glycemic
control
⢠quarterly- patients whose therapy has
changed or who are not meeting glycemic
goals
41. INSULIN THERAPY FOR TYPE 1 DIABETES
ďˇ MDI injections or continuous subcutaneous insulin infusion (CSII).
ďˇ Use insulin analogs to reduce hypoglycemia risk.
ďˇ screening those with type 1 diabetes for other autoimmune diseases
(thyroid, vitamin B12 deficiency, celiac) as appropriate.
42. PHARMACOLOGICAL THERAPY FOR
HYPERGLYCEMIA IN TYPE 2 DIABETES
ďˇ Metformin
ďˇ Insulin therapy
ďˇ If noninsulin monotherapy at maximal tolerated dose does
not achieve or maintain the A1C target over 3â6 months,
add a second oral agent, a glucagon-like peptide-1 (GLP-1)
receptor agonist, or insulin.
47. ADMINISTRATION OF INSULIN
o RI = 30-45 mins before meals.
o Short/rapid-acting insulin (Lispro, Aspart, glulisine) = within 20
mins or immediately before meals.
o Intermediate-acting insulin = in portions of 2/3 in the AM and 1/3
in the PM
o No insulin regimen produces the precise insulin secretory pattern
of the pancreatic islet
o S/E: hypoglycemia and weight gain
49. INITIATING INSULIN THERAPY IN TYPE I DM
Insulin requirement: usually 0.5-0.8 U/kg per day
A conservative daily dose of 0.4U/kg/day is given initially to a
newly diagnosed pt, then the dose is adjusted, using SMBG
values
50. INITIATING INSULIN THERAPY IN TYPE II DM
ďˇ Initiation of basal bolus insulin regimen in T2DM: calculate insulin requirement
at 0.3 to 0.5 units/kg/day
ďź 50% is given as basal insulin (2/3 given pre-breakfast and 1/3 given
pre-dinner)
- ex: intermediate- 20-0-10 ( 20 units pre-breakfast + 10 units pre-dinner)
ďź 50% is given as pre-meal insulin in divided doses prior to meals ( short
or rapid acting insulin pre-breakfast, pre-lunch, pre-supper)
- ex: regular â 4-4-4 ( 4 units pre-breakfast, 4 units pre-lunch, 4 units pre-supper)
51. Differentiation between Type 1 and Type 2 Diabetes
Mellitus, especially in younger individuals
Characteristics Type 1 Diabetes
Mellitus
Type 2 Diabetes Mellitus
Onset Acute-symptomatic Slow-often-asymptomatic
Clinical Picture Weight loss, polyuria,
polydipsia
If symptomatic, similar picture as T1 DM- weight
loss, polyuria, polydipsia
ď§ Obese
ď§ Strong family history of T2DM
ď§ Acanthosis NIgricans
ď§ Polycystic ovary syndrome (PCOS)
Ketosis Almost always present Usually absent
C-Peptide Low/absent Normal/elevated
Antibodies ď§ ICA positive
ď§ Anti-GAD positive
ď§ ICA 512 positive
ď§ ICA negative
ď§ Anti-GAD negative
ď§ ICA 512 negative
Therapy Insulin Lifestyle, oral anti-diabetic agents, insulin
Associated auto-
immune diseases
Yes No
â˘Adapted from Alberti Diab Care, 2004.8. ICA â islet cell antibodies; Anti-GAD â glutamic acid decarboxylase antibodies
52. Drug Dose Range Notes:
Glyburide (DiaBeta
ÂŽ
,
Micronase
ÂŽ
)
1.25 to 20 mg QD or divided BID Glipizide is best absorbed when taken 30 minutes
prior to meals. Elderly patients and those with
decreased renal function should be started on lowest
doses.
Glyburide SR (Glynase
ÂŽ
) 1.5 to 12 mg QD
Glipizide (Glucotrol) 5 to 40 mg QD or divided BID
Glipizide SR (Glucotrol
ÂŽ
XL) 5 to 20 mg QD
Glimepiride (Amaryl
ÂŽ
) 1 to 8 mg QD
Metformin (Glucophage
ÂŽ
) Initial dose: 500 BID
Maximum dose: 2550 mg/day divided BID or TID WM
Note cautions in renal impairment. Note cautions for
patients undergoing procedures requiring contrast
media. Higher doses of Glucophage
ÂŽ
may be the best
tolerated given TID.
Glucophage
ÂŽ
XR Initial dose: 500 QD
Maximum Dose: 2000 mg/day
Conversion from Glucophage
ÂŽ
to Glucophage
ÂŽ
XR: Same total daily
dose, but once a day up to maximum daily dose of 2000 mg/day
Pioglitazone (Actos
ÂŽ
) 15 to 45 mg QD Onset of action 2 weeks, maximum effects in 2 to 3
months. Thiazolidinediones may cause resumption of
ovulation.
Rosiglitazone (Avandia
ÂŽ
) 4 to 8 mg QD or divided BID
Nateglinide (Starlix
ÂŽ
) 60 to 120 mg TID WM Do not take dose if meal skipped.
Repaglinide (Prandin
ÂŽ
) 0.5 to 4 mg TID to QID WM Maximum dose: 16 mg/day
Acarbose (Precose
ÂŽ
) 25 to 100 mg TID WM Take with first bite of meal. Initial dose 25 mg QD and
titrate upward to minimize gastrointestinal effects.
Miglitol (Glyset
ÂŽ
) 25 to 100 mg TID WM
Glyburide/Metformin
(Glucovance
ÂŽ
)
Initial dose: 1.25 mg glyburide/250 mg metformin QD,
Maximum dose: 10 mg glyburide/2000 mg metformin divided BID WM
See above notes for glyburide and metformin
55. RECOMMENDED ANNUAL LABORATORIES
ď Lipid profile
ď Liver function tests
ď Urinalysis
ď Serum creatinine
ď TSH in T1DM, dyslipidemia and women > 50 y/o
ď Dilated eye exam
56. WHO SHOULD UNDERGO LABORATORY TESTING
FOR DIABETES/PREDIABETES?
⢠individuals with any of the risk factors for Type 2 diabetes
mellitus.
57. Previously identified IGT or IFG
both IFG and IGT RR* 12.13 (4.27-20.00)
isolated IGT RR 5.52 (3.13-7.91)
isolated IFG RR 7.54 (4.63-10.45)
GDM RR 7.43 (4.79-11.51)
PCOS
OR for IGT (BMI-matched) 2.54 (1.44, 1.47)
OR for DM2 (BMI-matched) 4.00 (1.97, 8.10)
Overweight or obesity
BMI > 25 kg/m (OR men 1.52 women 1.59)
WC > 90 cm for males and > 80 cm for females (OR men 1.54 women 1.70)
Waist-hip ratio > 1 for males and > 0.85 for females (OR men 1.53 women 1.50)
First-degree relative with DM
(parents or siblings)
OR 2.13 (1.22-3.71)
Sedentary lifestyle
RR for DM based on average hours spent watching TV per week (0-1, 2-10, 11-20, 21-
40, >40): RR 1.00, 1.66, 1.64, 2.16, and 2.87
Conditions assoc with insulin
resistance (acanthosis nigricans)
OR 1.97 (1.18-3.27)
HPN
Increased blood pressure, per 1 SD:
Systolic: RR 1.56 (1.31-1.85)
Diastolic: RR 1.52 (1.27-1.83)
CVD DM as a CVD risk factor (age- and sex-adjusted): HR 2.5 (1.9 to 3.2)
Schizophrenia OR 2.07 (1.03 to 4.15)
High TG, low HDL or both
Increased triglycerides, per 1 SD: OR 1.70 (1.62-1.78)
Increased apolipoprotein A-I, per 1 SD: OR 0.76 (0.62â0.92)
â˘RR= relative risk
58. OTHER CORNERSTONES OF MANAGEMENT
ď§ Medical nutrition therapy -registered dieticians
ď§ Weight loss
ď§ Primary prevention of T2DM
ďź Moderate weight loss â 7% TBW
ďź Exercise of 150 min/week
ďź Diet (reduced calories and fat)
ďź Fiber intake of 14g of fiber/1000 kcal
ďź Saturated fat intake - <7%
ďź Medications
59. IN WHAT SETTING/S SHOULD TESTING
FOR DIABETES BE DONE?
⢠Testing should ideally be carried out within the healthcare
setting
⢠clinics, hospitals, local health centers) because of the need
for follow-up and discussion of abnormal results by qualified
health care professionals (nurse, diabetes educator, physician
60. IF INITIAL TEST/S ARE NEGATIVE FOR DIABETES,
WHEN SHOULD REPEAT TESTING BE DONE?
⢠Repeat testing should ideally be done annually.
⢠at least at 3-year intervals âindividual will develop significant
complications of diabetes within 3 years of a negative result
⢠ADA 2010 -repeat testing annually for those with IFG and/or IGT.
⢠CDA 2008 -more frequent testing in those with multiple risk
factors.
⢠AACE 2007 -annual testing for all those with risk factors.
61. SUMMARY OF RECOMMENDATIONS: SCREENING FOR DIABETES
AMONG ASYMPTOMATIC ADULTS
⢠All individuals -evaluated annually for risk factors for type 2 diabetes and pre-diabetes.
⢠Obesity, pre-diabetes, components of the metabolic syndrome, PCOS, previous GDM, family
history and schizophrenia
⢠Universal screening using laboratory tests is not recommended as it would identify very few
individuals who are at risk.
⢠Laboratory testing for diabetes and pre-diabetes is recommended for those who have risk
factors for Type 2 diabetes mellitus.
62. ⢠Laboratory Testing - > 40 yo
⢠Earlier testing if with at least one other (other than age) risk factor for
diabetes.
⢠Testing -health care setting (clinics, hospitals, local health centers)
because of the need for follow-up and discussion of abnormal results
by qualified health care professionals (nurse, diabetes educator,
physician).
⢠Testing at any setting should be supervised by a qualified health care
professional.