Slide 1 Pathophysiology of Diabetes Mellitus Lisa Knight, MD October 6, 2017 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 2 Disclosures • No financial disclosures ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 3 Lecture Objectives • Be familiar with the physiology of diabetes mellitus • Understand the differences between type 1 and type 2 diabetes • Be aware of treatment options for patients with type 1 and type 2 diabetes ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________
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Diabetes Mellitus Lisa Knight, MD Pathophysiology of ...XI. Uncommon forms of immune -mediated diabetes A. Stiffman syndrome B. Type B insulin resistance X. Gestational Diabetes Mellitus
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Slide 1
Pathophysiology of Diabetes Mellitus
Lisa Knight, MD
October 6, 2017
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Slide 2 Disclosures
• No financial disclosures
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Slide 3 Lecture Objectives
• Be familiar with the physiology of diabetes mellitus
• Understand the differences between type 1 and type 2 diabetes
• Be aware of treatment options for patients with type 1 and type 2 diabetes
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Slide 4 Literal definitions
• Diabetes
– Greek word meaning “siphon” or “to pass through”
• Mellitus
– Latin word meaning “honey”
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Slide 5 Early Diabetes Treatments
1000 AD: Greek physicians recommended horseback riding to
reduce excess urination
1800s Bleeding, blistering, and doping were common
Early 1900s Oat cure, potato therapy, milk diet, rice cure, and
opium
1915 Leading American diabetologist, recommended a
starvation diet Admitted to the hospital
Coffee with whiskey Q2 hrs until no glucosuria (from 7a until 7p)
Usually lasted about 5 days
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Slide 6 Diabetes: Major Therapeutic Breakthrough
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Slide 7 VIII. Diseases of the exocrine pancreas
A. Cystic fibrosis
B. Trauma/pancreatectomy
C. Neoplasia
D. Pancreatitis
E. Hemochromatosis
IX. Endocrinopathies
A. Acromegaly
B. Cushing’s syndrome
C. Glucagonoma
D. Pheochromocytoma
E. Hyperthyroidism
F. Somatostatinoma
G. Aldosteronoma
X. Drug or Chemical-Induced
A. Corticosteroid-induced
B. Others
X. Infections/Critical Illness
XI. Uncommon forms of immune-mediated diabetes
A. Stiffman syndrome
B. Type B insulin resistance
X. Gestational Diabetes Mellitus
I. Type 1 diabetes
II. Type 2 diabetes
III. Atypical diabetes (Flatbush)
IV. Latent Autoimmune Diabetes in Adults (LADA)
V. Neonatal diabetes
A. Transient
B. Permanent
VI. Maturity-Onset Diabetes of Youth (MODY)
A. MODY1
B. MODY2
C. MODY3
D. MODY4
E. MODY5
F. MODY6
G. MODY7
VII. Mitochondrial Diabetes
VII. Genetic defects in insulin action
A. Type A insulin resistance
B. Rabson-Mendenhall syndrome
C. Leprechaunism
D. Lipoatrophic diabetes
The ADA recognizes >50 different forms of diabetes
• Insulin to Carb Ratio can be used as often as the patient eats• Correction formula should not be used more than every 2-3 hours
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Slide 29 Abnormal Blood Glucose Symptoms
Hypoglycemia
• Shaky
• Sweaty
• Anxious
• Dizzy
• Hunger
• Blurry Vision
• Weakness/Fatigue
• Confusion/Altered Mental Status
• Irritable
Hyperglycemia
• Polydipsia
• Polyuria
• Headaches
• Trouble concentrating
• Blurry Vision
• Fatigue
• Irritability
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Slide 30 Hyperglycemia Management
• If BG ≥240 mg/dL, check urinary ketones– Follow diabetes action plan provided by endocrine provider
• Small/trace negative ketones– Give correction dose of insulin per action plan– Resume normal BG checking/management
• Moderate ketones– Give correction dose of insulin +1 unit– Encourage water intake– Recheck BG level and urine ketones in 2 hours and repeat
• Large Ketones– Give correction dose of insulin +2 units– Encourage water intake– Recheck BG level and urine ketones in 2 hours and repeat
– If by the 3rd check, urine ketones remain moderate or large, call the endocrine provider
– On insulin pump—consider pump site change if moderate or large ketones develop
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Slide 31 Hypoglycemia Management
• In general, BG < 70 mg/dL
– If unconscious, having a seizure, or unable to tolerate PO, give glucagon 1 mg (>20 kg) or 0.5 mg (<20kg) IM
– If tolerating PO, give 15-20 grams of simple CHO and recheck BG in 15-20 minutes (repeat if still < 70 mg/dL)
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Slide 32 Management: Type 2 Diabetes
HbA1c >9% or significant ketosis or ketoacidosis
Diagnosis
HbA1c ≤ 9% and mildly symptomatic or
asymptomatic without ketosis
Insulin; diet/exercise; Metformin
Diet/exercise; Metformin
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Slide 33 Metformin
• Biguanide
• Mechanisms of action
– Decreases hepatic glucose output
– Increases peripheral tissue insulin sensitivity
• First line oral medication for pediatric type 2 diabetes
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Slide 34 Excerpt from the Discovery of Insulin
By: Micheal Bliss
A physician’s description of the painful wasting death of many people with diabetes before insulin was discovered:
"Food and drink no longer mattered, and often could not be taken. A restless drowsiness shaded into semi-consciousness. As the lungs heaved desperately to expel carbonic acid (as carbon dioxide), the dying diabetic took huge gasps of air to try to increase his capacity. 'Air hunger' the doctors called it, and the whole process was sometimes described as 'internal suffocation.' The gasping and sighing and sweet smell lingered on as the unconsciousness became a deep diabetic coma. At that point the family could make its arrangements with the undertaker, for within a few hours death would end the suffering."