Diabetes
mellitus
Introduction
Insipidus
Sugar Type
1 Type
2
Pancreas Insulin
Diagnosis
Fasting > 7 Random
> 11.1 (WHO
criteria)
Glucose
physiology
3.5 - 8 mmol per
litre Renal threshold is 11 mmol/l
The brain must have
glucose Glucose
lowered by - insulin
Glucose raised by -
glucagon, adrenaline, cortisol, growth hormone
Aetiology
Type 1
MZ twins 30 - 35% Diabetic
father 1:20 - 40 chance per child
Viral à autoimmunity Peak
incidence 10 - 13 years, spring and autumn
Incidence has doubled
over past 30 years
Fibrotic disease of the pancreas will lead to insulin deficiency
Type 2
MZ almost 100% 1st
degree relatives 25%
Obesity 50%
due to beta cell loss
50% from increased
insulin resistance
Presentation
Polyuria Thirst Weight
loss Lack
of energy Blurred
vision
Puritis Candida
infection
In type 1 the beta
cells die over a two year period, but the disease may appear to start on a
specific day due to a stress or infective trigger factor
Complications
Staphylococcal skin
infections Retinopathy Polyneuropathy Impotence
Arterial
microvascular Arterial
macrovascular Renal
Insulin resistance Hypoglycaemia
Screening
May go undiagnosed
for years
Smoking
Treatments
Diet alone Diet
and oral Diet
and insulin
Insulin may be short
acting or long acting mixed with protamine or zinc
Diet
Complex carbohydrates Calories -
matched to requirements
Absorption if insulin
Hot - fast Cold
- slow Tummy -
fastest Leg
- in between Arm
- slowest
Hypoglycaemia
Say a blood sugar of below 2.5 mmol/l
Causes
Too much insulin Not
enough food Vigorous
exercise Infections
Onset - 5 - 20
minutes after injection of soluble insulin, several hours after slower acting
insulins.
Signs and symptoms
from release of adrenaline from the CNS when blood sugar falls
rapidly
nervousness from release of adrenaline from the CNS when blood sugar
falls rapidly
sweating tremor pallor tachycardia palpitations
from depression of the CNS when blood sugar levels fall
headache light-headedness confusion emotional
change
inappropriate behaviour slurred
speech memory
lapse
lack of co-ordination staggering
gait double
vision drowsiness
convulsions coma numbness
of the lips and tongue
Management
Eat sugar IV.
glucose 50 mls of 50%
dextrose IM
glucagon Medalert
Hyperglycaemia
Ketoacidosis and coma
Causes
failure to take insulin insufficient
insulin resistance
to insulin
systemic infections physiological
stress
Onset
slow, days rather than hours
Early features
Polyuria thirst malaise drowsiness abdominal pain Headache
weakness shortness
of breath fever hot
dry skin.
Later features
Kussmaul breathing sweetish
odour of breath lowered
BP
Drowsiness coma glucose
ketones
and protein in the urine
DKA
Diabetic ketoacidosis
Causes
Stabilisation Disruption
to insulin therapy
Stress of intercurrent infection Insulin
should never be stopped
Omit insulin only
when patient will not be eating for whatever reason
Pathogenesis
In DKA there is uncontrolled
catabolism associated with insulin deficiency
Insulin inhibits
hepatic ketogenesis
Increased serum
glucose Ketones
Hyperglycaemia and glucosurea Acidosis
Osmotic diuresis Vomiting
Fluid
and electrolyte depletion
Renal
hypoperfusion
Impaired
excretion of ketones and hydrogen ions
Patient
education
Food
Insulin
Activity and exercise
Urine testing shows
glucose > 11
Blood tests
Glycosylated HB
IDDM - no HGV PSV PPL
Type 1
Abrupt onset of,
weight loss muscle
wastage weakness polyuria polydipsia
polyphagia hyperglycaemia glycoseuria osmotic
diuresis
electrolyte imbalance ketosis
Type 2 diabetes
Insidious onset of,
fatigue drowsy
after meals irritability
nocturea
pruritis
poorly healing skin blurred
vision loss
of weight muscular
cramps
stress will induce hyperglycaemia
but
symptoms may be absent in mild cases.
Management.
Dietary
Aim is to achieve
normal body weight and normal growth.
Meal plan should
contain adequate calories, proteins, vitamins, minerals
Adults require 30
calories/kg/day of ideal body weight.
Increase this by
35-40 calories/Kg for children and very active adults.
Reduce this by 15-25
calories/ Kg for obese and sedentary adults.
Carbohydrate should
be 60% of total calories.
Try to give the right
sort of fat, so HDLs are increased and LDLs are decreased.
Protein 0.5 - 1.2g/Kg
Use high fibre food.
Use complex
carbohydrates.
Vary menu to individuals cultural background/preferences.
Ensure there is
enough CHO on board to correspond to insulin dosage.
Prevent/treat
obesity.
No smoking.
Moderation in C2H5OH
Use BDA exchange list
to vary the menu.
Teach patient how to
measure and calculate portions.
Routine Blood sugar
assays.
Exercise
Promotes metabolism
and increases use of CHO, therefore lowers insulin requirements.
Enhances
the effect of insulin.
Prevents arterial
disease, improves blood lipid ratios.
Insulin therapy
A
form of HRT.
Effects various aspects of metabolism.
One
or more injection a day.
Human insulin made by
bacterial with human genes in them.
Prescribed in U-100,
100 iu. per ml.
Use British standard
1 or 2 ml insulin syringe.
26-28
G needle, usually orange.
(higher the number the thinner the needle).
Dose may be titrated.
Regular
urine tests.
Ask patient to keep
own records.
Attend OPD, Gly. Hb.
Avoid hypoglycaemia.
Complication of
insulin therapy
Allergy,
usually only local.
Lipidodystrophy, may present as fat atrophy or hypertrophy.
Oedema, generalised
fluid retention
Insulin resistance,
over 200 iu./day in the absence of infection
NB. Surgery, change
in activity or infection can alter control.
Long term
complications of diabetes
Increases
likelihood of strokes and IHD.
Amputations for
gangrene occur in smokers and diabetics, diabetic neuropathic and vascular
complications.
Life expectancy in
young diabetics is two thirds that of their contempories.
Microvascular
complications occur less frequently if blood sugar level is well controlled.
Macrovascular
complications
Results from
thickening of the capillary basement membranes, this also occurs in the
glomeruli causing glomerulosclerosis
Seems to be
associated with poor control
Often accounts for
skin complications and peripheral nerve damage
Major vessels are
also affected with the usual consequences
Renal complications
The usual picture of
chronic renal failure - Diabetic neuropathy
Effects the
peripheral and autonomic NS
Feet
watch out for lesions compare
the colour in both feet
check for temperature check
for fungal infections
check for volume of pulses keep
warm
professional help remember
possible analgesia
Diabetic retinopathy
Most common cause of
blindness in 35-64 years of age
Half of the diabetic
population ten years after diagnosis have some
Caused by haemorrhage
into the vitreous, formation if scar tissue and detachment
Treat with
photocoagulation, yearly funduscopy, prevent with
good control