diabetes mellitus

							            DIABETES MELLITUS
                Dr.Gazmend Bojaj
             Family Medicine Specialist
                    March-2009

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Introduction:

• Diabetes is a disorder that affects the body's
    ability to produce or take insulin.Insulin is
    hormonal product in the pancreas that enables
    cells of the body to process glucose (blood
    sugar) for energy.
•   Diabetes results in abnormal levels of glucose in
    the blood stream.
•   This can cause short-term and long-term
    unenviable consequences ranging from lack of
    insulin, worsening the condition of the heart and
    sexual dysfunction.

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                    Dr.Gazmend Bojaj
What is diabetes?
• Diabetes mellitus is a group of metabolic
    diseases characterized by high figures of sugar
    (glucose), which is due to the fault of the
    secretion of insulin in the pancreas gland.
•   Diabetes mellitus was first identified as the
    sweet urine disease in the old world. Diabetes-
    Greek (frequent urination), mellitus (sweet)



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PATHOPHYSIOLOGY
• Pancreas is composed of cells scattered
  throughout the so-called islands of Langerhans
• Two types of cells are important for control of
  glucose:
• Alpha cells - produce glukagon
    Hormone that is opposite to insulin action
    Causes the release of glucose from the cell
     repository
• Beta cells produce insulin
    enable the body cells to use and store
     carbohydrates, fats and proteins


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            Dr.Gazmend Bojaj
Forms of diabetes include:
• Diabetes type 1. Autoimmune disease that does
  insulin-producing cells in the pancreas, while this usually
  happens during childhood.


• Diabetes type 2. Metabolic disorder that usually
  includes obesity and stability of insulin. This is the most
  frequent type of diabetes and usually occurs in adults.


• Diabetes during pregnancy. Temporary condition
  that may impact any pregnant woman.


• Secondary diabetes.      It is caused by other diseases
  such as pancreatitis or medical treatment such as the
  corticosteroids therapy. Dr.Gazmend Bojaj
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• Autoimun latent diabetes in adults. A variation of type 1
   diabetes that typically develops after age 30 years.

• Diabetes that affects the immaturity of youth. A rare and
   not inheritable disorder that causes diabetes among
   people with specific genetic defects.




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Classification of diabetes
( based on recommendations of WHO and ADA )


                DM type 1
                DM type 2
 • Prevalence of DM:
 DMT1 – 10 %
 DMT2 – 90 %



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                    Dr.Gazmend Bojaj
The process of increasing blood glucose




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            Dr.Gazmend Bojaj
The origins of diabetes is complex. In
most cases diabetes begins with one of
these two processes:

• Metabolic.
Lifestyle factors such as excessive eating,
 less physical activity and obesity could impair
 the body's ability to produce insulin. This is
 called resistance in insulin.
Uncontrolled risk factors such as genetic
 factors, family history and age may also have
 impact.
Metabolic forms of diabetes include:
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                    Dr.Gazmend Bojaj
• Diabetes type 2. This includes 90-95% of all
   cases of diabetes, based on U.S. National
   Institute for Health (NIH).

• Most of these patients had prediabetes which
   was not controlled.

• This is considered a disease of middle-aged and
   the elderly. Type 2 also in recent times is seen
   even with younger people, and increases the
   obesity in childhood.



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• Autoimmune. The body's immune system could
    mistakenly destroy beta cells that produce insulin in
    the pancreas. Autoimmune diabetes causes are hardly
    understood, but genetic and family factors play a role
    in this process, and viruses and other environmental
    factors are believed to be the cause.
•   Autoimmune forms of diabetes include:

Diabetes type 1. Commonly known as Juvenile
    diabetes as this form mainly develops in children and
    young people.

Autoimmune latent diabetes with adults.This variation
    of type 1 may be developed later in life.
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            Dr.Gazmend Bojaj
MAIN FORMS OF DIABETES

• Diabetes type 1

• Diabetes type 2

• Diabetes during pregnancy (gestational)

• Secondary diabetes
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  DIABETES – TYPE I
• Resulting from the destruction of beta cells
  leading from primary to full deficiency of
  insulin.

• It is also caused by genetic defects of beta cell,
  genetic defects in insulin action, other
  endocrine and exocrine malfunctions, drugs,
  other genetic syndromes.




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    DIABETES – TYPE I
• With rare frequency.
• Usually begins before age 15 years.
• Frequency: Males> than women.
• Speedy and immediate attack
• The rapid advancement in these acidoze and coma
• Usually patients are thin and underweight
• Insulin-deficient: at the beginning the youth with
  diabetes produce more insulin than normal, but soon
  beta cells get tired and the diabetic patient becomes
  "open" with degenerated cells and practically with no
  insulin.
• Plasma insulin - is completely absent. There is no
  insulin response to glucose load.
• Insulin therapy - is necessary for control of these
  cases

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DIABETES – TYPE II
• Frequency-more common.
• Occurs in middle aged individuals. More common
    in females.
•   The attack is secret.
•   It is usually mild. Ketoacidosis is rare.
•   It is followed by obesity in 2/3 of cases. Usually
    detected during routine urine control.
•   Beta cells normally react. Relative deficiency of
    insulin may be due to antagonism of insulin.
•   Plasma levels of insulin can either be normal or
    increased.
•   Oral hypoglycemic factors and diet control are
    useful during treatment.


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SECONDARY DIABETES
• This type of diabetes usually occurs as a result
  of other chronic deceases.
• Pancreatic diabetes:
   – Pancreatitis
   – Hemochromatosis
   – Cancer of the pancreas.
• Abnormal concentration of hormonal
  antagonists
   – Hyperthyroidism
   – Hypercorticism: Cushing's syndrome
   – Hyperpituiarism : as acromegaly
   – Irregular activity of glucagon.
• Iatrogenic
   – According to some genetic disorders, this
     might come as a result of long use of
     corticosteroids, tiasidic diuretics
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DIABETES DURING PREGNANCY
• Gestational diabetes mellitus (GDM) during
  pregnancy is defined as any degree of glucose
  intolerance with the onset or first identification
  during pregnancy.
• SYMPTOMS:
 Glycosuria.
 High blood glucose.
 Usually occurs in the 24-28 weeks of pregnancy.
 Hyperglycemia rate is not as severe as in other
  types of diabetes.




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FACTORS OF DIABETES MELLITUS

• Inherited
• Autoimmunity
• Infections
• Obesity
• Diet
• Antagonism of insulin

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Diabetes risk factors
• Inheritance and genetic factors.
Several types of disordered genes are
  recognized as causes of diabetes of the young
  people (MODYN) and Wolfram syndrome.
• Weight
Excess weight and obesity are key factors for
  type 2 diabetes and diabetes during pregnancy.



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• Sex. Despite the fact that men are less than 49
    percent of the adults in the US, they account for 53
    percent of cases with diabetes in adults, according to
    National Health Institutes.
•   Level of physical activity. Lack of regular exercise is
    thought to be the cause of majority of global
    epidemics of obesity and diabetes.
•   Diets. Effect of diet in the development of diabetes is
    controversial.
•   Hormones. These chemical elements can contribute in
    diabetes in different manners. For example, such as
    cortisol stress hormones.


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• Viruses. Some peoples are diagnosed with type 1
    diabetes after any viral infection. Viruses that were
    thought to be related to diabetes type 1 are also
    mumps.
•   Smoking. Smoking is a risk factor for type 2 diabetes
    and perhaps even for other forms of diabetes.
•   Alcohol. Excessive use of alcohol is also a risk factor
    for diabetes. For example, alcohol can cause
    pancreas.




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Risk           Factors for Complications
Rates of Risk Factors for Complications per 100 Adults with Diabetes, United States, 2007
In 2002, 17.4% of U.S. adults with diabetes smoked, 38.7% reported being physically inactive, and,
based on self-reported height and weight, 80.5% were overweight and 46.1% were obese. In 2001,
63.3% of U.S. adults with diabetes reported having hypertension.




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CLINICAL SIGNS AND
SYMPTOMS
• Polyuria
• Polydipsia
• Polyfagia
• Tiredness and fatigue
• Diabetic ketoacidosis
• Hypercholesterolemia leading to aterosclerosis
• Losing weight
• Hemoconcentration-Hyperciscosity about
  dehydration - Concentrated thick blood-
  Hypoperfusion-increased flow
• Hypokalemia and Hyponatremia
• Kussmaul breathing
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  Three main symptoms:
• Polyuria:
    Very increased frequency urination
    Osmotic diuresis presented with glucose in urine
    Water loss mostly with potassium, chlorine and
     sodium.
• Polydipsia:
    Mostly due to dehydration of the body
• Polyfagia:
    Cells do not get glucose, wherein the body
     consequently remains hungry all the time.



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  Chronic complications

• Two different forms in blood vessels:
   Macro vascular:
     • Coronary heart disease, cerebrovascular insult &
         peripheral vascular disease
       • Heart attack (myocardial infarction) risk factors

   Micro vascular:

       • Nephropathies (Kidney dysfunction), neuropathy (nerve
           dysfunction); & retinopathy (vision problems)
       •   Blindness is 25 times more frequent
       •   Microaneurysm
       •   Neovascularity
       •   The male erection dysfunction (ED)

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    DIABETIC RETINOPATHY
• Early stage of retinopathy
• Increased exudates in the
    center of the retina (macula).
•   Microaneurysm (small bulge in
    the retinal blood circulation
    often in the form of spots.
•   Retinal hemorrhage (inflated
    blood stains that penetrate the
    retina).
•   Macular edema (swelling /
    thickening of macula).                      Retina showing NPDR
•   Macular ischemia (closure of
    small blood vessels /
    capillaries).
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Diabetic retinopathy




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Diabetic ulcers




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Diabetic ischemia




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Diabetic gangrene




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Diabetes diagnosis methods
• Doctors use glycemic tests to diagnose diabetes.
    This kind of test tells us exactly the amount of
    glucose with persons in the blood stream.
•   Glucose is measured by milligrams per deciliter
    (mg / dL) in blood.
•   Results of glucose 100 mg / dL are normal.
•   Glucose between 100 - 125 mg / dL is
    considered prediabetes.
•   Glucose around 125 mg / dL represents
    diabetes.


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• During pregnancy, usually around week 24-
  28, women can be tested for gestational
  diabetes through glycemic test, which
  stimulates the body to produce glucose.
• Blood is tested one hour after the patient
  drinks 50 grams glucose.
• If results are abnormal, then we do a more
  complex analysis that is called Oral Glucose
  Tolerance Test (OGTT) to confirm diabetes.



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 TREATMENT

• All treatments must be made together
  with diet, exercise and stress
  management
• There are two types of treatment to
  control diabetes:
    Oral antidiabetic
    Insulin


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Options of diabetes treatment:
• U.S. Administration has approved oral diabetes
    medication only for the treatment of type 2
    diabetes.
•   Doctors sometimes use drugs to treat the health
    condition in cases of prediabetes, insulin
    resistance and Polycystic ovary syndrome:

• Oral diabetes medications include:

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• Sulfonylureas

• Biguinides

• Thiazolidinediones

• Alpha–glycosidase inhibitors

• Meglitinides


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    l.Sulfonylureas
    tolbutamide, glibenclamide, gliclazide,
    chlorpropamide
The above act by stimulating the pancreas B cell - ↑ insulin

 The main side effects: hypoglycemia, weight gain, increased
    insulin level.
   Contraindications: pregnancy, renal insufficiency, weakened
    lungs performance, DMT1 and diabetes caused by acute
    pancreatitis.
   Recommended to be taken in the morning or at noon.
   Hypoglycemic effect of Sulfonylureas is most frequent in the
    elderly.
   When used together with BAIJS-hypoglycemic effects can be
    highlighted.
   Not recommended for obese patient.
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                               Dr.Gazmend Bojaj
ll. Biguinides

• METFORMIN:- ↓ Hepatic glucose
   production, ↓ insulin resistance in
   peripheral tissues, ↓ Trigl, ↓ LDL cholest, ↓
   associated with weight in the obese (first
   line therapy for obese).




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                      Dr.Gazmend Bojaj
• SPECIAL INDICATIONS- with the obese,
  dyslipidemia

• SIDE EFFECTS-anorexia, nausea, diarrhea, abdominal
  discomfort, lactic acidosis and deficit of vitamin B12


• Contraindications
 Renal diseases when creatinine is> 1.4mg/dl (F) and>
  1.5mg/dl (M)
 Severe heart insufficiency
 Pulmonary diseases with predisposition for cellular hypoxia
 Hepatic diseases
 Pregnancy
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    lll.Thiazolidinediones
TROGLITAZONE ( Rezulin )
PIOGLITAZONE ( Actos )
ROSIGLITAZONE ( Avandia )

• The above are youngest group of oral antidiabetics.
• They act by reducing insulin resistance in peripheral
    tissues, and inhibit glycogenesis in liver.
•   With patients who take insulin, the addition of
    thiazolidinediones has resulted in significant
    replacement of daily insulin needs.

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    lV. Alpha-glycosidase inhibitors
           ACARBOSE ( Precose )
           MIGLITOL ( Glycet )

• The above act by inhibiting the absorption of
    carbohydrates from food (tr. GI), therefore, their
    main effect consists on hyperglycemia
    postprandial.
•   They are indicated as monotherapy, or combined
    with sulfonylurea, to DMT2
•   KI: sem.inflamat. of intestinal, partial obstruction
    of the bowel, and colon ulcers, cirrhosis of the
    Liver
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            v.Meglitinides
            REPAGLINIDE ( Prandin )
            NATEGLINIDE ( Starlix )

• Meglitinides act as insulin secretagogues (qel.B stimulate
  the pancreas).
• They act quickly, in 15-30 minutes, and quickly reduce
  hyperglycemia postprandial.
• Patients should take the drug before meals or with food,
  2-4 x / day.




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  Diet – physical activity

 Taking of at least five meals a day, fruits and vegetables,
 Replacing of animal fats with vegetable fats,
 Meat meals with fish (rich in unsaturated fats-Omega3)
 Cellulose-rich food (beans, legumes and other plants
  more nutritious)
 Physical exercise (aerobics, biking, walking, swimming,
  wherein in 6 weeks it enables reduced HbA1c to 1-
  1.5%), at least 30 min. / Day.
 Self monitoring of blood glucose


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     Management of DM type 2
• Be active around 30 minutes during the day.
  Ask your doctor what activities are best for you.

• Take the book of diabetes and at the same time see the
  level of blood glucose each day.

• Every day when you measure your blood sugar dose,
  record the number in the records book. Call your doctor
  and ask if the values are too high or too low for 2-3 days.

• Check the level of the lower fat, ulcers, swelling, redness,
  or toes ulcers.

• Do not smoke.
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       INSULIN TREATMENT
• Indications:
DM type 1( children, adults )
DM gestational,
Hyperglycemic coma,
DM type 2: secondary resistance with
 barriers
 *when the fasting level >7.0, after
 lunch >10.0 HbAlc >7.5% ( not so
 strict with elder people )
Surgery.
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Taking insulin for type 1 diabetes




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• Initial dose is 0.3 UI / kg / day,
• 5-6 servings per day, with a good diet
• The time of receipt must coincide with the time
    of food (about 30 minutes before meals),
•   Part of the body-(most commonly the abdomen)
•   The technique of taking, mixing, shaking,
•   Tools for taking (syringes-40UI/ml, PEN-
    100UI/ml)
•   Gradual change (1-2 UI / per case)
•   Adapted to physical activity, meal-time habits,
    menstruation, kidney function.


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INSULIN
• Protocol:
     – Single doze:

     – Two dozes: 2/3 before breakfast; 1/3 in
       the evening

     – Three dozes: morning, midday, evening

     – Four dozes: before meals, bedtime
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References of diabetes mellitus
• Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency
    Medicine: Concepts and Clinical Practice. 5th Ed. St. Louis, Mo:
    London: Mosby; 2002:801-813. Townsend, Jr., CM, ed. Sabiston
    Textbook of Surgery. 17th Ed. Philadelphia, PA: Elsevier; 2004:5...
    http://yourtotalhealth.ivillage.healthline.com/adamcontent/burns/2#
    references
•   http://yourtotalhealth.ivillage.com/diabetes-
    basics.html?pageNum=2
•   http://yourtotalhealth.ivillage.com/increase-in-diagnostic-imaging-
    fueled-by-self-referring-doctors.
•   Defeat Diabetes Naturally
•   www.YourDiabetesCure.com - Learn How To Control Your
    Blood Sugar Levels Without Using Medication.
•   Reverse Diabetes Now
•   www.diabetesreversalreport.com - To Reverse Diabetes
    DRUG FREE In 4 Weeks Using Safe Proven Remedies.
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• Thanks for your attention!




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                Dr.Gazmend Bojaj
            KLINA CITY




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