Diabetes Mellitus in pregnancy " Gestational diabetes mellitus''
Diabetes Mellitus Zhao-xiaojuan. Introduction Diabetes mellitus is a heterogeneous group of...
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Transcript of Diabetes Mellitus Zhao-xiaojuan. Introduction Diabetes mellitus is a heterogeneous group of...
Introduction
Diabetes mellitus
is a heterogeneous group of
metabolic diseases characterized by
hyperglycemia resulting from defects
in insulin secretion, insulin action, or
both.
Introduction
The chronic hyperglycemia of
diabetes is associated with long-
term damage, dysfunction, and
failure of various organs, especially
the eyes, kidneys, nerves, heart,
and blood vessels.
Symptoms
PolyuriaPolydipsia (thirst)Weight lossWeaknessPolyphagiaBlurred visionRecurrent infectionImpairment of growth
Criteria for diagnosis of diabetes (WHO1999)
Symptoms of diabetes +
Casual plasma glucose ≥ 1.1mmol/l(200mg/dl)
Or
FPG ≥ 7.0mmol/l (126mg/dl)Or
2-hPG ≥ 11.1mmol/l
Diagnostic Criteria WHO1999
IGT
-FPG<7mmol/L
-2-h PG≥7.8mmol/L and <11.1mmol/L
IFG
-FPG≥6.1mmol/L and <7.0mmol/L
Laboratory Findings
Urinary glucose
Urinary ketone
Blood glucose (FPG and 2-hPG)
HbA1c and FA(fructosamine)
OGTT
Insulin / CP releasing test
Classification (1)
Type 1 diabetes β-cell destruction, usually leading to
absolute deficiency Immune-mediated diabetes Idiopathic diabetes
Type 2 diabetes Ranging from predominantly insulin
resistance with relative insulin deficiency to predominantly an insulin secretory defect with insulin resistance
Classification (2)
Other specific types of diabetes Due to other causes, e.g.,genetic defects
in insulin action, diseases of the exocrine pancreas, drug or chemical induced
Gestational diabetes mellitus(GDM) diagnosed during pregnancy
Etiologic classification of diabetes mellitus(1)I.Type 1diabetes ( -cell destruction, usually leading to absolute insulin deficiency ) A. immune mediated B. IdiopathicII.Type 2diabetes ( may range from predominantly insulin resistance with relative insulin
deficiency to a predominantly secretory defect with insulin resistance )III.Other specific types A. genetic defects of -cell function 1. Chromosome 12, HNF-1 (MODY3) 2. Chromosome 7, glucokinase (MODY2) 3. Chromosome 20, HNF-4 (MODY1) 4. Mitochondrial DNA 5. Others B. Genetic defects in insulin action 1. Type A insulin resistance 2. Leprechaunism 3. Rabson- Mendenhall syndrome 4. Lipoatrophic disease 5. Others C. Diseases of the exocrine pancreas 1. Pancreatitis 2. Trauma / pancreatectomy 3. Neoplasia 4. Cystic fibrosis 5. Hemochromatosis 6. Fibrocalculous pancreatopathy 7. Others
Etiologic classification of diabetes mellitus(2) D. Endocrinopathies 1. Acromegaly 2. Cushing’s syndrome 3. Glucagonoma 4. Pheochromocytoma 5. Hyperthyroidism 6. Somatostatinoma 7. Aldosteronoma 8. Others E. Drud- or chemical-induced 1. Vacor 2. Pentamidine 3. Nicotinic acid 4. Glucocorticoid 5. Thyroid hormone 6. Diazoxide 7. -adrenergic agonists 8. Thiazides 9. Dilantin 10. -Interferon 11. Others F. Infections 1. Congenital rubella 2. Cytomegalovirus 3. Others
Etiologic classification of diabetes mellitus(3) G. Uncommon forms of immune- mediated diabetes
1. “Stiff-man” syndrome
2. Anti-insulin receptor antibodies
3. Others
H. Other genetic syndromes sometimes associated with diabetes
1. Down’s syndrome
2. Klinefelter’s syndrome
3. Turner’s syndrome
4. Wolfram’s syndrome
5. Friedreich’s ataxia
6. Huntington’s chorea
7. Laurence-moon-Biedl syndrome
8. Myotonic dystrophy
9. Porphyria
10. Prader-Willi syndrome
11. Others
IV. Gestational diabetes mellitus ( GDM )
Patients with any form of diabetes may require insulin treatment at some stage of their disease. Such use of insulin dose not, of itself, classify the patient.
Type 1 DMGenerally <30 years
Rapid onset
Moderate to severe symptoms
Significant weight loss
Lean
Ketonuria or keto-acidosis
Low fasting or post-prandial C-peptide
Immune markers(anti-GAD,ICA,IA-2)
Type 2 DM
Generally > 40 years
Slowly onset
Not severe symptoms
Obese
Ketoacidosis seldom occur
Nonketotic hyperosmolar syndrome
Normal or elevated C-peptide levels
Genetic predisposition
Pathophysiological model for development of obesity and T2DM
Beta-cell defect
Intra-uterin growth
retardation
InsulinResistance
genes
Obesity genes
InsulinResistance
+Intraabdominal
obesity
IGT T2DM
Westernlifestyle
Glucosetoxicity
MetabolicInsulin
Resistance(FFA)
0 804020 60
Year
Disorder of glycemia: etiological types clinical stages
Stages
Types
Normoglycemia Hyperglycemia Diabetes mellitus
Type 1
Type 2
Other specific types
Gestational diabetes
Normal glucose tolerance
IGT and/or
IFGNot insulin requiring
Insulin requiring for control
Insulin requiring for survival
Acute,life-threatening consequences
Hyperglycemia with ketoacidosis
Nonketotic hyperosmolar syndrome
Macrovascular complications
Atherosclerotic cardiovascular disease
Peripheral vascular disease
cerebrovascular disease
Potential chronic complications of elevated HbA1c
good poorcontrol
RIS
K
•Microalbuminuria•Mild Retinopathy•Mild Neuropathy
•Albuminuria•Macular Edema•Proliferative Retinopathy•Peridontal Disease•Impotence•Gastroparesis•Depression
•Foot Ulcers•Angina•Heart Attack•Coronary Bypass•Surgery•Stroke•Blindness•Amputation•Dialysis•Kidney Transplant
The Aims of TreatmentRelief of hyperglycemic symptomsCorrection of hyperglycemia, ketonuria and hyperlipidemiaEstablishment and maintenance of a desirable body weight, and in children normal growth and developmentAvoidance of acute metabolic disturbancePrevent or delay the onset of the long-term complications
Targets for controlOptim
al Fair Poor
Plasma glucose (mmol/L)
FPG
2-hPG
4.4-6.1
4.4-8.0
7.0
10.0
>7.0
>10.0
HbA1c(%) < 6.2 <6.2-8.0 >8.0
Blood pressure (mmHg)
<130/80 >130/80-<160/95
>160/95
BMI(kg/m2)
Male
female
<25
<24
<27
<26
27
26
Total cholesterol(mmol/L) <4.5 4.5 6.0
HDL- cholesterol(mmol/L) >1.1 1.1-0.9 <0.9
Triglycerides(mmol/L) <1.5 <2.2 2.2
LDL- cholesterol(mmol/L) <2.5 2.5-4.4 >4.4
Management
Essentials of management
Monitoring of glucose levels
Food planning
Physical activity
Treatment of hyperglycemia
2.Monitoring of Glucose Levels
Blood glucose levels
- before each meal
- at bedtime
Urine glucose testing
Urine ketone tests (should be performed during illness or when blood glucose is 20mmol/L )
3.Food Planning
Weight control.
50-60%of the total dietary energy should come from complex carbohydrates.
20-25% form fats and oils.
15-20% from protein.
Restrict alcohol intake.
Restrict salt intake to below 7g/d.
4.Physical Activity
Physical activity play an important role in the management of diabetes particularly in T2DM. Physical activity improves insulin sensitivity, thus improving glycemic control, and may help with weight reduction
Do sparingly avoid sedentary activities
Do regularly participate in leisure activities and recreational sports
Do every day adopt healthy lifestyle habits
5.Drug Treatment
If the patient is very symptomatic or has
a very high blood glucose level, diet and
lifestyle changes are unlikely to achieve
target values. In this instance,
pharmacological therapy should be
started without delay.
Treatment
Sulphonylureas
Biguanides
-Glucosidase inhibitors
Thiazolidinediones
Glinides
Insulin
Combination therapy
1.Sulphonylureas
Chlorpropamide
Tolbutamide
Glibenclamide
Glipizide
Gliclazide
Gliguidone
Glimepiride
Management Algorithm for Overweight and Obese T2DM
Diet Exercise and weightcontrol
Failure Add biguanide, TZD or -glucosidase inhibitors
Failure
Failure
Combine two of these or add sulphonylurea or glinide
Add insulin or change to insulinCheck adherance at each step
Management Algorithm for Non-Obese T2DM
DietExerciseand weightcontrol
Failure
Failure
Failure
Add sulphonylurea, biguanide, -glucosidase inhibitors or glinide
Combine sulphonylurea or glinide with biguande and/or -glucosidase inhibitors and/or add TZD
Add insulin or change to insulinCheck adherance at each step