You are on page 1of 111

Diabetes Mellitus

Types 1 & 2
Jessica Perini, MD
Sect. Endocrinology
WVU Dept of Internal Medicine
March 14, 2017
Diabetes definition
Outline
Classic symptoms
Diagnosis
Fundamental differences between DM types 1 & 2
Pancreatic failure
Relative insulin insufficiency
Insulin resistance
Therapies
Pre-Diabetes
Labs
Prevention
Risk Factors
Complications of diabetes
Microvascular
Macrovascular
Why we treat
Sugars help microvascular complications
BP and cholesterol help macrovascular complications
How we treat
Pills, injections, insulin, pumps, surgery, transplants
Monitoring, health maintenance
Is it working?
CBG
CGM
A1c, lipids, urine microalb/creat, eye exams
Clinical Pearls: When youre a resident
Diabetes
Means increased urine

Mellitus honey

Insipidus bland

Diabetes mellitus lots of sweet pee


Diabetes Mellitus
Classic Symptoms
Diabetes Mellitus
Classic symptoms

Polyuria
Polydipsia
Polyphagia
Weight loss
Blurry vision
Diagnosis
4 methods
Diagnosis
HbA1c 6.5

FBS > 125

2hour OGTT 200

Random glucose 200 plus


symptoms
Whats an A1c ?
Glycosylated hemoglobin
Measure every 3 months

Shows average level of circulating


sugar over ~ 3months time

5% = 97 7% = 154 9% = 212
6% = 125 8% = 183 10% = 240
2 Primary Types of DM
Type 1

Type 2

(others)

Whats the difference?


DM Type 1
Autoimmune disorder

Insulin-producing Beta cells of


pancreas are destroyed
DM Type 1
Absolute Lack of Insulin

Patients need insulin injections


immediately and forever
DM Type 1
Much less common than Type 2

Of all patients with DM in the U.S.,


10-15% have DM type 1
vs.
85-90% have DM type 2
DM Type 1
At what age does it start? Any

With what BMI is it associated?


Any
DM Type 1
~ Unique qualities:

DKA (diabetic ketoacidosis)


Labile sugars (brittle)
Higher highs
Lower lows
Very sensitive to insulin, not resistant
to insulin
A little insulin will have a dramatic effect
Case # 1 BL
26yo man presents to ER with c/o
nausea, vomiting, abdom pain,
sweating, weakness
Approx 4 weeks prior to ER visit, had
had URI and sore throat which resolved
spontaneously
Weight was stable
Polyuria, nocturia, polydipsia
Nausea started about 2-3 days ago, now
abd pain
Case #1 BL contd
PE:

BP 98/68 P 88 RR 16 Ht 59
Wt 158 lbs
Pale, mild abdominal discomfort with
palp, no rebound, skin damp, areas of
vitiligo over abdomen and right hand
Case #1 BL contd
Labs:

Na 132 Gluc 588


K 5.3 U ket large
Cl 105 A1c 12.2
CO2 8
Phos 2.5
WBC 16
Case #1 BL contd
What is a lab value that we need?

What is his diagnosis?


Case #1 CS contd
Anion Gap Na - (Cl + CO2)

Normal Gap < 12

His Gap: 132 - (105 + 8) = 19

DKA
Case #1 CS contd
He was admitted to ICU

Started insulin drip and ivfs

In prep for discharge, started SQ


injections, gave DM education,
nutritional counseling
Case #1 CS
What kind of diabetes does he have?
Confirm Diagnosis
How do we know this is Type 1
Diabetes?
Labs
C-peptide with glucose
Anti-GAD Abs (glutamic acid
decarboxylase)

Anti-islet Abs

Usually DKA occurs only in Type 1


Diabetes Type 1
Insulin absence

Absolute insulin deficiency

Associated with other autoimmune


disorders
Questions?
Diabetes Type 2
Relative Insulin Deficiency
DM Type 2
Much more common
Much less dramatic onset (gradual
process)
Patients have had worsening sugar
levels for years

By the time of diagnosis, i.e. by the time


sugars are high enough to earn the dx of
DM,
50-70% of beta cells are already non-
functioning or destroyed
Pre-Diabetes
The in-between stages

Not normal but not diabetes


Whats Normal Sugar

Fasting < 100

Post-Prandial < 140


Gray Zone
Fasting

Normal < 100 Diabetes > 125


Impaired Fasting Glucose
IFG

FBG 100 125


Impaired Glucose Tolerance
IGT

2-hour PPG 140 - 200


A1c

5.7 6.4 % suggests abnormal


glucose levels
Whats Wrong with this
Picture?
Case #2 EM
55yo with h/o HTN, dyslipidemia; FHx DM;
routine visit

Labs (fasting):
Na 137 K 4.0 BUN/Creat 12/1.2
Glucose 92

disconnect
Repeat labs (still fasting):
Glucose 91
A1c 7.5
A Disconnect ?

She has IGT, with post-prandial


sugars in the 170s range

This is how we miss the diagnosis of


DM if we only check FBS
Questions?
Risk Factors for DM2
IFG and IGT
h/o gestational DM
Obesity
Distribution of weight (central obesity)
Metabolic syndrome (increased waist circ, high
TGs, low HDL, HTN, IFG)
Inactivity
FHx
Race (non-white)
Age (esp. > 45)
Diabetes Type 2
What happens?
Diabetes Type 2
What happens?

Insulin resistance
Diabetes Type 2
DM Type 2
Sugar floats around in the blood
Tries to clear into cells
Cells need to open
Insulin helps the cells open
Cells resist the insulin
DM Type 2
Then what?

To overcome the resistance, the


cells make more insulin
DM Type 2
Then what?
Over time, the cells get worn out
Over time, the cells get damaged
DM Type 2
Then

Sugars start to rise


Whats the Problem with High
Sugars?
Thick and sticky
Complications
Short-Term
Blurry vision, polyuria, polydipsia, UTIs,
yeast infx

Long-Term
Microvascular
Macrovascular
Microvascular Complications
Retinopathy
Nephropathy
Neuropathy
Retinopathy

Normal
Retinopathy
Diabetic Retinopathy
Affects 40-90% of people with DM

Leading cause of blindness in U.S. < age


60

Blindness can usually be prevented with


sugar control, regular exams, treatment as
needed

Annual dilated eye exams required


Diabetic Nephropathy
Affects ~ 40% of people with DM

DM is most common cause of CKD in


U.S.

Annual urine albumin:creatinine


ACE-I, ARB
BP control
Diabetic Neuropathy
Most common:
Distal symmetric sensorimotor
polyneuropathy
up to 50% have no symptoms
vibration sense lost first
Autonomic
cardiovascular autonomic
neuropathy = independent risk factor
for CV mortality
resting tachycardia, orthostasis, ED,
gastroparesis, sweating
Diabetic Peripheral
Neuropathy

Loss of Sensation
Diabetic Peripheral
Neuropathy
Foot Ulcers
Diabetic Peripheral
Neuropathy
Charcot Foot
Diabetic Peripheral
Neuropathy
Charcot Foot
Diabetic Peripheral
Neuropathy
Affects up to 70% of people with DM

50 60% of people with LE amputation have had


the loss as consequence of DM &/or PAD

Can be slowed by good sugar control

Amputations can be reduced by good foot care:


Visual inspection daily
Podiatry visits
Proper footwear
Microvascular Complications
How to help?

Sugar control -- lifestyle changes,


medications
Macrovascular
Complications
Increased risk stroke, MI, PAD

What is the leading cause of death in


patients with DM?
Macrovascular
Complications
Increased risk stroke, MI, PAD

Leading cause of death in patients


with DM?

Heart disease
Macrovascular
Complications
How to help?

Control blood pressure -- lifestyle,


meds
Control lipids -- lifestyle, meds
Statin use in most (monitor lipid
panel but treat regardless)
Smoking cessation
Other Complications of DM
Other Complications of DM
Cancer (liver, pancreas, endometrium,
breast, bladder, colon/rectum)
Fatty Liver
Depression
OSA
Fractures
Periodontal disease severity (not prevalence)
Low testosterone
Dementia and cognitive decline
Questions So Far?
Mini Summary:

Type 1 DM = lack of insulin, DKA, labile


sugars, autoimmune

Type 2 DM = relative lack of insulin in face


of resistance, eventually cells are
exhausted and there is an absolute
deficiency, genetics and lifestyle more
important in development
Treatment
Why?
How?
Goals?
Monitoring
Other things
Why Treat?
Improve microvascular complications
with good sugar control

Improve macrovascular complications


with good BP and cholesterol control

At any given age, a person with


diabetes is 2x more likely to die than
one without DM.
How to Treat?
Diet
Reduce carbohydrates
Reduce overall calories

Exercise
150 minutes per week moderate
intensity aerobic exercise (this is the
minimum for maintanance)
resistance exercise 2x per week
Non-Sugar Treatment
BP control < 140/80
Cholesterol control LDL < 100,
near 70

Some get ASA

Pain medication for neuropathy


Pregabalin, duloxetine, nortriptyline,
other
How to Treat?
Treat those with Pre-Diabetes!

5 7% weight loss +/- medications can


reduce risk of progression to DM in
patients with pre-DM by up to 58%
How to Treat Diabetes?
Medications

Oral
Non-insulin injections
Insulin
Bariatric surgery
Pancreatic transplant
Oral DM Medications

Metformin (regular and long-acting)


DPP-4 inhibitors (only brands exist still: januvia/sitagliptin,
tradjenta/linagliptin, onglyza/saxa)
TZDs (pioglitazone)
Bromocriptine (brand: cycloset)
SGLT-2s (only brands exist:
invokana/canagliflozin,farxiga/dapa)
Glinides (nateglinide/starlix, repaglinide/prandin)
Amylin mimetics (only brand exists: symlin)
Colesevelam (brand: welchol)
AG inhibitors (acarbose/precose)
SUs (glipizide, glimepiride, glyburide) (think: yuck!)
Case # 3 MJ
65yo man with HTN, CAD, presents
for check-up
Inactive, smokes, some occasional
burning in feet esply at night
Meds: carvedilol, ASA
PE: obese with BMI 38, BP 148/88
A1c 7.8, HDL 29, LDL 123, TG 210,
Creat 1.10
What do you want to do?
Oral DM Medications
Always think of METFORMIN first
Non-Insulin Injectables
GLP-1 agonists (only brands exist
still):

byetta/exenatide
victoza/liraglutide
bydureon/exenatide
trulicity/dulaglutide
tanzeum/albiglutide
Case # 3 MJ contd
Confirm with repeat A1c
Diet
Exercise
Smoking cessation
Refer for DM education/nutrition
Add ACE-I
Add statin
Check urine microalbumin:creatinine ratio
Exam for neuropathy
Can wait 3 months and repeat a1c. Meds now or in 3
months. *I* would start metformin and liraglutide
now.
Insulin
The only option in treating Type 1
Typically added later in Type 2

Long-acting insulin
Short-acting insulin

Pre-Mixed insulin
Methods of Administering Insulin

Single shot per day


Multiple shots per day

Bottles/vials
Pens

Pumps, other devices


Bottles/Vials
Pens
Pumps
Pumps
Pumps
Insulin Delivery Devices
Who Can Use a Pump?
Who Can Use a Pump?

Anyone with insulin requirements


Bariatric Surgery
For patients with diabetes and BMI >
35

Bariatric surgery can reduce sugars


to normal for indefinite period of time
Pancreatic Transplant
If the surgery is successful, patients
can live with normal glucose levels
for up to 7 years or more
Is the Chosen Treatment
Working?

Monitoring sugars
Sugar Goals
Normal fasting sugar is

Normal post-prandial sugars is


Sugar Goals
Normal fasting sugar is < 100

Normal post-prandial sugars is <


140
Sugar Goals in Diabetes
Fasting: < 110 130
PPG: < 160 180

A1c: < 6.5 or < 7.0

Why the difference? Why not try to


get to normal? => because we are
doing this artificially
Hypoglycemia
Glucose levels ~ < 65
Yikes. Be afraid.
Increases risk of cognitive problems
Risk of death
May explain why tighter sugar control in some
trials was associated with increased mortality
Hypoglycemia unawareness (when people have
frequent episodes that they stop recognizing
the symptoms) => let their sugars run high
(decrease their insulin)
Treatment: eat, drink, glucagon injection
Monitoring Sugars
Capillary Blood Glucose
Continuous Glucose Monitor
A1c
Google lens?
Axillary sweat?
Glucometers
Continuous Glucose
Monitors
Other Options?
How Often/When to Check
Sugars?
Varies from patient to patient

Fasting
Pre-Meal
2 hours after Meal
Bedtime
If sensation of low sugar
When You are a Resident
Resident Situation # 1
You are called by nurse at 3 a.m.
because Ms. Smiths CBG is 300.
What do you do/ say/ ask next?
Resident Situation # 1
contd
What have her sugars been lately?
Is this an anomaly? Should we repeat the CBG?
Has she had any low sugars?
What medications is she on?
Steroids? Immunosuppressants?
Is she getting any insulin currently?
How much? 5 units per day? 100s of units per day?
Do we know if she is type 1 or type 2?
Is she thin or heavy? Young or old? How is her
kidney function?
Resident Situation #1
contd
Sliding scales are used all the time
For a given sugar, administer a given amount of
insulin
BE CAREFUL with sliding scales, especially in the
middle of the night in a patient you dont know

Remember about sensitivity!!!!


A 280 lb patient with type 2 DM may need 50
units for a sugar of 300.
A 180 lb patient with type 1 DM may need 3
units. 50 units would potentially kill her.
Resident Situation # 2
Patient is admitted to ICU for DKA
Insulin gtt is started
Sugars are now good, averaging
110s

What do you do next?


Resident Situation # 2
contd
DO NOT stop the insulin drip

DO NOT stop the insulin drip until the


anion gap is CLOSED

Once gap is closed, overlap with


long-acting basal insulin by an
hour, then can stop the drip
Resident Situation # 2
contd
But patients sugars are now down to
60 and her AG is still 17.

What can you do?


Resident Situation # 2
contd
But patients sugars are now down to
60 and her AG is still 17.

What can you do? Start D5 or D10


in ivfs.
Summary (page 1 of 3)

Type 1 diabetes -- requires insulin no matter what


-- sensitive to insulin
-- often has labile sugars
-- autoimmune d/o

Type 2 diabetes -- lifestyle interventions can help


-- risk factor reductions can help
-- oral medications can help
-- may progress to insulin
-- resistant to insulin
-- more genetic
Summary (page 2 of 3)

Watch for, monitor for, prevent, treat


associated comorbidities, complications
-- Hypoglycemia
-- HTN
-- dyslipidemia
-- eye damage, kidney disease, neuropathy
-- screen for other autoimmune d/os in DM1
-- appropriate vaccinations
Summary (page 3 of 3)

Treat high sugars with appropriate


therapy
Its a lot of trial and error
Diabetes progresses over time and what
worked before wont work forever
Keep the patient safe. Avoid lows.
The End
Any Questions?

You might also like