diabetes mellitus presentation and complications

 Diabetes mellitus (DM) is a group of diseases
characterized by high levels of blood glucose resulting
from defects in insulin production, insulin action, or
both.
 The term diabetes mellitus describes a metabolic
disorder of multiple aetiology characterized by chronic
hyperglycaemia with disturbances of carbohydrate, fat
and protein metabolism resulting from defects in
insulin secretion, insulin action, or both.
 The effects of diabetes mellitus include long–term
damage, dysfunction and failure of various organs.

 Diabetes mellitus may present with characteristic
symptoms such as thirst, polyuria, blurring of vision,
and weight loss.
 In its most severe forms, ketoacidosis or a non–ketotic
hyperosmolar state may develop and lead to stupor,
coma and, in absence of effective treatment, death.
 Often symptoms are not severe, or may be absent, and
consequently hyperglycaemia sufficient to cause
pathological and functional changes may be present for
a long time before the diagnosis is made.

 The long–term effects of diabetes mellitus include
progressive development of the specific
complications of retinopathy with potential
blindness, nephropathy that may lead to renal
failure, and/or neuropathy with risk of foot ulcers,
amputation, Charcot joints, and features of
autonomic dysfunction, including sexual
dysfunction.
 People with diabetes are at increased risk of
cardiovascular, peripheral vascular and
cerebrovascular disease.

 Type 1 Diabetes Mellitus
 Type 2 Diabetes Mellitus
 Gestational Diabetes
 Other types:
LADA (latent autoimmune diabetes)
MODY (maturity-onset diabetes of youth)
Secondary Diabetes Mellitus

 Was previously called insulin-dependent diabetes
mellitus (IDDM) or juvenile-onset diabetes.
 Type 1 diabetes develops when the body’s immune
system destroys pancreatic beta cells, the only cells in
the body that make the hormone insulin that regulates
blood glucose.
 This form of diabetes usually strikes children and young
adults, although disease onset can occur at any age.
 Type 1 diabetes may account for 5% to 10% of all
diagnosed cases of diabetes.
 Risk factors for type 1 diabetes may include
autoimmune, genetic, and environmental factors.

 Was previously called non-insulin-dependent diabetes mellitus
(NIDDM) or adult-onset diabetes.
 Type 2 diabetes may account for about 90% to 95% of all
diagnosed cases of diabetes.
 It usually begins as insulin resistance, a disorder in which the
cells do not use insulin properly. As the need for insulin rises,
the pancreas gradually loses its ability to produce insulin.
 Type 2 diabetes is associated with older age, obesity, family
history of diabetes, history of gestational diabetes, impaired
glucose metabolism, physical inactivity, and race/ethnicity.
 African Americans, Hispanic/Latino Americans, American
Indians, and some Asian Americans and Native Hawaiians or
Other Pacific Islanders are at particularly high risk for type 2
diabetes.
 Type 2 diabetes is increasingly being diagnosed in children and
adolescents.

 A form of glucose intolerance that is diagnosed in some
women during pregnancy.
 Gestational diabetes occurs more frequently among
African Americans, Hispanic/Latino Americans, and
American Indians. It is also more common among obese
women and women with a family history of diabetes.
 During pregnancy, gestational diabetes requires
treatment to normalize maternal blood glucose levels to
avoid complications in the infant.
 After pregnancy, 5% to 10% of women with gestational
diabetes are found to have type 2 diabetes.
 Women who have had gestational diabetes have a 20% to
50% chance of developing diabetes in the next 5-10 years.

 Latent Autoimmune Diabetes in Adults (LADA) is a
form of autoimmune (type 1 diabetes) which is
diagnosed in individuals who are older than the
usual age of onset of type 1 diabetes.
 Alternate terms that have been used for "LADA"
include Late-onset Autoimmune Diabetes of
Adulthood, "Slow Onset Type 1" diabetes, and
sometimes also "Type 1.5
 Often, patients with LADA are mistakenly thought
to have type 2 diabetes, based on their age at the
time of diagnosis.

 MODY – Maturity Onset Diabetes of the Young
 MODY is a monogenic form of diabetes with an autosomal
dominant mode of inheritance:
◦ Mutations in any one of several transcription factors or in the
enzyme glucokinase lead to insufficient insulin release from
pancreatic ß-cells, causing MODY.
◦ Different subtypes of MODY are identified based on the mutated
gene.
 Originally, diagnosis of MODY was based on presence of
non-ketotic hyperglycemia in adolescents or young adults in
conjunction with a family history of diabetes.
 However, genetic testing has shown that MODY can occur at
any age and that a family history of diabetes is not always
obvious.

Secondary causes of Diabetes mellitus include:
 Acromegaly,
 Cushing syndrome,
 Thyrotoxicosis,
 Pheochromocytoma
 Chronic pancreatitis,
 Cancer
 Drug induced hyperglycemia:

 Prediabetes is a term used to distinguish people who
are at increased risk of developing diabetes. People
with prediabetes have impaired fasting glucose (IFG) or
impaired glucose tolerance (IGT). Some people may
have both IFG and IGT.
 IFG is a condition in which the fasting blood sugar level
is elevated (100 to 125 milligrams per decilitre or
mg/dL) after an overnight fast but is not high enough
to be classified as diabetes.
 IGT is a condition in which the blood sugar level is
elevated (140 to 199 mg/dL after a 2-hour oral glucose
tolerance test), but is not high enough to be classified
as diabetes.

 Progression to diabetes among those with
prediabetes is not inevitable. Studies suggest that
weight loss and increased physical activity among
people with prediabetes prevent or delay diabetes
and may return blood glucose levels to normal.
 People with prediabetes are already at increased risk
for other adverse health outcomes such as heart
disease and stroke.

 Research studies have found that lifestyle changes can
prevent or delay the onset of type 2 diabetes among
high-risk adults.
 These studies included people with IGT and other high-
risk characteristics for developing diabetes.
 Lifestyle interventions included diet and moderate-
intensity physical activity (such as walking for 2 1/2
hours each week).
 In the Diabetes Prevention Program, a large prevention
study of people at high risk for diabetes, the
development of diabetes was reduced 58% over 3
years.

 Studies have shown that medications have been successful in
preventing diabetes in some population groups.
 In the Diabetes Prevention Program, people treated with the drug
metformin reduced their risk of developing diabetes by 31% over 3
years.
 Treatment with metformin was most effective among younger,
heavier people (those 25-40 years of age who were 50 to 80 pounds
overweight) and less effective among older people and people who
were not as overweight.
 Similarly, in the STOP-NIDDM Trial, treatment of people with IGT
with the drug acarbose reduced the risk of developing diabetes by
25% over 3 years.
 Other medication studies are ongoing. In addition to preventing
progression from IGT to diabetes, both lifestyle changes and
medication have also been shown to increase the probability of
reverting from IGT to normal glucose tolerance.

Management of
Diabetes Mellitus

 The major components of the treatment of
diabetes are:

 Diet is a basic part of management in every
case. Treatment cannot be effective unless
adequate attention is given to ensuring
appropriate nutrition.
 Dietary treatment should aim at:
◦ ensuring weight control
◦ providing nutritional requirements
◦ allowing good glycaemic control with blood glucose
levels as close to normal as possible
◦ correcting any associated blood lipid abnormalities

 Physical activity promotes weight reduction and
improves insulin sensitivity, thus lowering blood
glucose levels.
 Together with dietary treatment, a programme of
regular physical activity and exercise should be
considered for each person. Such a programme
must be tailored to the individual’s health status
and fitness.
 People should, however, be educated about the
potential risk of hypoglycaemia and how to avoid
it.

 There are currently four classes of oral anti-
diabetic agents:
i. Biguanides
ii. Insulin Secretagogues – Sulphonylureas
iii. Insulin Secretagogues – Non-sulphonylureas
iv. α-glucosidase inhibitors
v. Thiazolidinediones (TZDs)

 If glycaemic control is not achieved (HbA1c > 6.5%
and/or; FPG > 7.0 mmol/L or; RPG >11.0mmol/L)
with lifestyle modification within 1 –3 months,
ORAL ANTI-DIABETIC AGENT should be initiated.

As first line therapy:
 Obese type 2 patients, consider use of metformin,
acarbose or TZD.
 Non-obese type 2 patients, consider the use of
metformin or insulin secretagogues
 Metformin is the drug of choice in
overweight/obese patients. TZDs and acarbose are
acceptable alternatives in those who are intolerant
to metformin.

Combination oral agents is indicated in:
 Newly diagnosed symptomatic patients with
HbA1c >10
 Patients who are not reaching targets after 3
months on monotherapy

 If targets have not been reached after optimal dose of combination
therapy for 3 months, consider adding intermediate-acting/long-
acting insulin (BIDS).
 Combination of insulin+ oral anti-diabetic agents (BIDS) has been
shown to improve glycaemic control in those not achieving target
despite maximal combination oral anti-diabetic agents.
 Combining insulin and the following oral anti-diabetic agents has
been shown to be effective in people with type 2 diabetes:
◦ Biguanide (metformin)
◦ Insulin secretagogues (sulphonylureas)
◦ Insulin sensitizers (TZDs)(the combination of a TZD plus insulin is not an
approved indication)
◦ α-glucosidase inhibitor (acarbose)
 Insulin dose can be increased until target FPG is achieved.

Short-term use:
 Acute illness, surgery, stress and emergencies
 Pregnancy
 Breast-feeding
 Insulin may be used as initial therapy in type 2 diabetes
 in marked hyperglycaemia
 Severe metabolic decompensation (diabetic ketoacidosis,
hyperosmolar nonketotic coma, lactic acidosis, severe
hypertriglyceridaemia)
Long-term use:
 If targets have not been reached after optimal dose of combination
therapy or BIDS, consider change to multi-dose insulin therapy.
When initiating this,insulin secretagogues should be stopped and
insulin sensitisers e.g. Metformin or TZDs, can be continued.

 Patients should be educated to practice self-care.
This allows the patient to assume responsibility
and control of his / her own diabetes
management. Self-care should include:
◦ Blood glucose monitoring
◦ Body weight monitoring
◦ Foot-care
◦ Personal hygiene
◦ Healthy lifestyle/diet or physical activity
◦ Identify targets for control
◦ Stopping smoking

diabetes mellitus presentation and complications

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