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Diabetes Mellitus | Hyperglycemia | QuadBloggers

ByDanish syed

Oct 26, 2021 ,
Diabetes Mellitus

Diabetes Mellitus subsequently refers to a group of common metabolic disorders that share the phenotype of hyperglycemia.

Moreover, It is one of the leading causes of end-stage renal disease with non-traumatic lower extremity amputations and cardiovascular diseases.

Additionally, It is one of the leading causes of morbidity and mortality in India.

Diabetes Mellitus

Classification:

1.Type-1 Diabetes:

  • It develops as a result of autoimmunity against the insulin-producing beta cells that result in complete or near-complete insulin deficiency.

2.Type-2 diabetes:

  • It develops as a heterogeneous group of disorders characterized simultaneously by variable degrees of impaired insulin secretion, insulin resistance , and increased hepatic glucose production.

3. Specific types of Diabetes:

  • A) Genetic defects or beta cell development
  • B) Transient neonatal diabetes all in all
  • C) Diseases indeed of exocrine pancreas-pancreatitis, pancreatectomy, neoplasia, cystic fibrosis, hemochromatosis
  • D) Genetic defects simultaneously in insulin action, including type A insulin resistance, Lipodystrophy syndromes.
  • E) Endocrinopathies- acromegaly, cushings’s syndrome, pheochromocytoma and hyperthyroidism.
  • F) Infections also- congenital rubella, cytomegalovirus, coxsakievirus.
  • G) Other genetic syndromes associated simultaneously with diabetes- Down’s syndrome, klinefeltor’s syndrome, turner’s syndrome and huntington’s syndrome.
  • 4) Gestational diabetes mellitus.

Criteria for diagnosis of diabetes mellitus:

  • A) Symptoms subsequently of diabetes plus random blood concentration of >200 mg/dl
  • B) Furthermore, Fasting plasma glucose > 126 mg/dl
  • C)Additionally, HBA1c levels of >6.5%
  • D) Moreover, 2 hours Plasma glucose levels of >200 mg/dl .

Screening :

  • Use of HBA1C and FBS as a method of screening procedure is recommended because :
  • A)Indeed, A large number of individuals who may have diabetes are asymptomatic and are unaware that they have the disease
  • B) Studies have shown that the disease is present close to 10 years before diagnosis .
  • C) Screening of diabetes of people ages >45 years is recommended every 3 years for early diagnosis and to start treatment initially to avoid any further complications .

Risk factors and signs for type-2 diabetes mellitus :

  • A) Family history of diabetes (Parents or siblings with type-2 diabetes)
  • B) Additionally, Overweight or Obesity related issues with BMI >25 kg/meter square
  • C) Furthermore, Physical inactivity or sedentary lifestyle .
  • D) Moreover, Race/ethnicity
  • E) Previously identified with HBA1C OR IFG
  • F) In addition, History of gestational diabetes mellitus
  • G) Simultaneously, Hypertension or blood pressure of >140/80 mg/dl
  • H) Moreover, HDL cholestrol levels of <35 mg/dl also
Diabetes Mellitus

Pathogenesis:

A) Type-1 Diabetes Mellitus:

  • It is defined as the immune mediated destruction of the pancreatic beta cells and insulin deficiency.
  • Age-Most commonly seen before the age group of 20 years .
  • In majority of patients simultaneously, autoantibodies act against the beta cell antigens which appear after this triggering effect, followed by progressive loss of insulin secretion.
  • Additionally, when there’s decrease in the beta cell function varies depending on clinical diabetes and others developing the disease after couple of years.
  • At autopsy, indeed many patients with long standing diabetes produce little amounts of insulin and some individuals with 50 years of the disease have insulin-positive cells in the pancreas.
  • The major susceptibility gene for type-1 diabetes is located subsequently in HLA region on chromosome 6.
  • The main immunological markers simultaneously involved with type-1 diabetes islet cell autoantibodies.

B) Type-2 Diabetes Mellitus :

  • It develops as a result of insulin resistance , abnormal insulin secretion , increased hepatic glucose production , abnormal fat metabolism and systemic low-grade inflammation are the main centers for developing type 2 diabetes mellitus .
  • Type-2 diabetes mellitus encompasses simultaneously a range of disorders with the common phenotype of hyperglycemia.
  • Furthermore, It usually occurs at younger age groups and older age groups a lower BMI.
  • Additionally, The most prominent genetic variant of transcription factor-7 gene 2 has been associated with type-2 diabetes mellitus.

Approach to the patient with diabetes mellitus:

  • Once the diagnosis is made for the cause of diabetes , emphasis on the symptoms related to diabetes ( acute or chronic ) and type of diabetes should be assessed .

A) History:

  • Complete medical history should be assessed simultaneously with aspects involving weight , family history , sleep history , risk factors for cardiovascular diseases , history of pancreatic disease , and symptoms of hyperglycemia like polyuria , polydipsia , weight loss , fatigue , weakness , burry vision , and frequent superficial infections , and slow healing of skin lesions after minor trauma .
  • Other initial factors simultaneously like previous HBA1C levels , self-monitoring of blood glucose levels frequency at which the patient has experienced hypoglycemia , complications and patients assessment about his knowledge on diabetes , exercise , nutrition and sleep history .

B) Physical examination:

  • Additionally, Aspects like weight and BMI , retina examination , orthostatic blood pressure , foot examination , peripheral pulses and insulin injection sites .
  • Annual foot examination should also be performed to assess blood flow , sensation , ability to sense touch , pinprick sensation , ankle reflexes , nail care , presence of foot deformities like charcot foot , claw toes and possible sites of ulceration on the foot .

C) Classification of diabetes mellitus in an individual patient:

  • 1) Type-1 diabetes mellitus:
    • Onset of disease present in less than 30 years age group
    • Furthermore, Lean body habitus
    • Additionally, Insulin therapy as initial therapy required
    • Moreover, Ketoacidosis development
    • Simultaneously, Autoimmune disorders like autoimmune thyroid disease , adrenal insufficiency , pernicious anemia , celiac disease and vitiligo.
  • 2) Type-2 diabetes mellitus:
    • In addition, Diabetic onset after the age of 30 years
    • Furthermore, in obese patients
    • Subsequently, Initial insulin therapy not required
    • Simultaneously, Associated conditions like insulin resistance , hypertension , cardiovascular disease , dyslipidemia and polycystic ovarian syndrome .

D) Laboratory assessment:

  • In addition, Serum insulin or C-peptide levels must be tested
  • Furthermore, A low C-peptide levels in the setting of an increased blood glucose levels may confirm a patient’s need for insulin
  • Moreover, Measurement of islet cell antibodies may be useful if the type of diabetes mellitus is not clear.

Treatment protocol :

Mechanism of actionExamplesHBA1C reductionAdvantagesDisadvantagesContraindication
1) Oral :
BiguanidesDecreased hepatic glucose production Metformin1-2 %Weight neutral , hypoglycemia avoided , Decreased CV events Diarrhea , nausea , lactic acidosis , vitamin B12 deficiencyRenal insufficiency , CHF , Hospitalized patients
Alpha glucosidase inhibitorsDecreased GI glucose absorptionVoglibose , acarbose,miglitol0.5-0.8 %Reduce post-prandial glycemiaGI flatulence, liver function test additionallyRenal/liver disease
Dipeptidyl peptidase IV inhibitors Prolong endogenous GLP-1 action : Increased glucose , Decreased glucagonLinagliptin , alogliptin , saxagliptin , sitagliptin0.5-0.8 %Well tolerated , does not cause hypoglycemiaAngioedemaReduced dose with renal disease
SulfonylureasIncreased insulin secretionGliclazide , glimerpiride , glipizide , glibornuride1-2 %Short onset of action , lower postprandial glucoseHypoglycemia , weight gainRenal/liver disease
NonsulfonylureasIncreased insulin secretionMitiglinide , nateglinide0.5-1.0 %Short onset of action , lower postprandial glucoseHypoglycemiaRenal/liver disease
Sodium-glucose cotransporter 2 inhibitorsIncreased renal glucose excretiondapagliflozin , canaglifozin , ertugliflozin0.5-1.0 %Decreased weight and BP , do not cause hypoglycemiaUrinary and genital infections , polyuria , dehydrationModerate renal insufficiency
ThiazolidinedionesDecreased insulin resistance , increased glucose utilizationPioglitazone , rosiglitazone0.5-1.4 %Lower insulin requirementsPeripheral edema , CHF , weight gain , fractures , macular edemaCHF , liver diseases

2) Parental:

Amylin AgonistSlow gastric emptying , Decreased glucagonPramlintide0.25-0.5%Reduce postprandial glycemia, weight lossInjection, nausea, increased risk of hypoglycemia simultaneously with insulinAgents that slow GI motility
GLP-1 receptor agonistIncreased insulin, decreased glucagon, slow gastric emptyingdulaglutide, semaglutide0.5-0.99%weight loss, does not cause hypoglycemiainjection nausea, increased risk of hypoglycemiarenal disease
Insulinincrease glucagon utilization, decreased hepatic glucose productionNot limitedknown safety profileinjection, weight gain, hypoglycemia all in all

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Please refer this book additionally for detailed description of diseases: Harrisons book of internal medicine

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