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Textbooks, references
Glucose, DM and hypoglycemia
Dr Y Hayden
Dept. Chemical Pathology, UFS
2015
Clinical Chemistry. 7th edition. Marshall WJ.
Bangert SK. Lapsley M.
JEMDSA 2012 Volume 17 Number 2
(Supplement 1) Page S1-S95
Clinical Biochemistry. Metabolic and clinical
aspects. 2nd edition. Marshall WJ. Bangert SK.

Outline of lecture Outline of lecture

Glucose homeostasis Complications of DM
Measurement of glucose concentration
Diabetes Mellitus Hyperglycemia
Type 1 DM Diabetic Keto Acidosis (DKA)
Type 2 DM Hyperglycemic Hyperosmolar State (HHS)
Other specific types
Gestational DM Hypoglycemia in DM
Diagnosis of DM Long term complications of DM
Monitoring Rx of DM
Intermediate hyperglycemia
Impaired fasting glucose
Impaired glucose tolerance

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Outline of lecture Glucose homeostasis

Hypoglycemia Carbohydrate fuel most basic form = glucose
Adults Glucose = only use-able form to erythrocytes,
central nervous system (CNS)
Childhood Sources of energy:
Causes Diet- carbohydrates
Investigations Endogenous production: glycogenolysis,
gluconeogenesis
Cases BG concentrations maintained within narrow limits in
health
Homeostasis regulates blood glucose levels: 2,5
8.0mmol/L

Hormones in glucose homeostasis

Principle hormone affecting blood glucose levels

Insulin Lowers blood glucose
Secreted: B-cells, islets of Langerhans, pancreas
Counter regulatory hormones: Main target tissues:
Liver
Glucagon Muscle
Adipose tissues
Cortisol
Increases blood Glucose cannot enter the cells in the absence of insulin
Catecholamines glucose Removes glucose form blood to cells through GLUT-4
Growth hormone transporter.
Molecule undergoes cleavage Insulin + C-peptide (NB in
hypoglycemia work-up)

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Insulin Fed State

Control of fat metabolism
Peripheral glucose uptake:
Stimulates lipoprotein lipase Insulin
muscle and adipose tissue

Inhibits hormone-sensitive lipase Hepatic glycogenesis

Insulin deficiency: NEFA from adipose Glycogenolysis and

gluconeogenesis
hepatic triglyceride synthesis -
Lipolysis, proteolysis and
Hypertriglyceridaemia (VLDL, chylomicron ketogenesis

increased)

Fasting State Glucagon

hormone secreted by the -cell of the
Peripheral glucose uptake
pancreatic islets
Glucagon
Glycogenolysis first hormone to be released when glucose
Gluconeogenesis levels fall
Insulin
Lipolysis acts on the liver: stimulates both
glycogenolysis and gluconeogenesis.

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Measurement of Glucose
Advanced Glycation end products
concentration
Plasma
Ongoing glycolysis in red
blood cells will decrease BG Non enzymatic glycosylation of tissue proteins is
Collect into tube containing the covalent attachment of glucose to free amino
NaF, inhibits glycolysis
Analyze shortly after sampling
acids on the protein with subsequent chemical
Whole blood
rearrangements.
Glucometer These modifications can seriously impact on
Monitoring protein function.
Not for DM diagnosis,
confirm with lab test However some of the glycosylation products are
Not accurate at extremely useful in monitoring glycaemia, e.g. Haemoglobin
low/high values A1 (HbA1c) and fructosamine.

HbA1c
HbA1c is the Hb-fraction that is changed by Adult Hemoglobin

attachment of a sugar glycation

Amount of glycation is proportional to blood HbA - 97% HbA2 - 2.5% HbF - 0.5%

glucose concentration
Reflects average blood glucose for lifespan
HbA1c
HbA1b
Glucose attached to N-
Pyruvate attached to -
HbA1a terminal of -chain
chains
80% of HbA
that RBC
Average RBC lifespan 120 days HbA1a1
Fructose-1,6-diphosphate
HbA1a2
Glucose-6-Phosphate

HbA1c reflects BG for the past 6 -8 weeks

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HbA1c for diagnosis
Reasons why HbA1c should be recommended
for the diagnosis of diabetes includes:
1. Standardized and aligned to the DCCT/UKPDS; measurement of glucose is less well
standardized
2. Better index of overall glycemic exposure and risk for long-term complications
3. Substantially less biologic variability
4. Substantially less preanalytic instability
5. No need for fasting or timed samples
6. Relatively unaffected by acute (e.g., stress or illness related) perturbations in
glucose levels
7. Currently used to guide management and adjust therapy
HbA1c for diagnosis
For the diagnosis of diabetes:
The HbA1c assay is an accurate, precise measure of chronic glycaemic
levels and correlates well with the risk of diabetes complications
The HbA1c assay has several advantages over laboratory measures of
glucose
Diabetes should be diagnosed when HbA1c is 6.5 %. Diagnosis should be
confirmed with a repeat HbA1c test. Confirmation is not required in
symptomatic subjects with plasma glucose levels >11.1 mmol/l
If HbA1c testing is not possible, previously recommended diagnostic
methods (e.g., FPG or 2hPG, with confirmation) are acceptable
HbA1c testing is indicated in children in whom diabetes is suspected but the
classic symptoms and a casual plasma glucose >11.1 mmol/l are not found
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HbA1c for diagnosis
However there are several limitations of A1c
as the recommended means of diagnosing
diabetes:
Some hemoglobin traits, such as HbS, HbC, HbF and HbE interfere with some of the
A1c assay methods
Any condition that changes the red cell turnover, such as hemolytic anemia, chronic
malaria, major blood loss, or blood transfusions, will lead to spurious A1C results
A1C levels appear to increase with age, but the extent of the change, whether it
relates to factors other than glucose metabolism, and the effect of the age-related
increases on the development of complications are not sufficiently clear to adopt age-
specific values in a diagnostic scheme.
HbA1c for diagnosis
For the identification of those at high risk for
diabetes:
The risk for diabetes based on levels of glycaemia is a continuum;
therefore, there is no lower glycaemic threshold at which risk clearly begins
The categorical clinical states intermediate glycaemic states, impaired
fasting glucose, and impaired glucose tolerance fail to capture the
continuum of risk and will be phased out of use as HbA1c measurements
replace glucose measurements
As for the diagnosis of diabetes, the HbA1c assay has several advantages
over laboratory measures of glucose in identifying individuals at high risk
for developing diabetes
Those with HbA1c levels below the threshold for diabetes but 6.0 %
should receive demonstrably effective preventive interventions. Those with
HbA1c below this range may still be at risk and, depending on the
presence of other risk factors, may also benefit from prevention efforts
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Fructosamine

Fructosamine is the glycation of albumin. It

has a shorter half life, i.e. 2 to 3 weeks. These
two methods can be used for long term
monitoring of glucose control (HbA1c- 2 to 4
months and fructosamin, 2 weeks).

Diabetes Mellitus Diabetes Mellitus

Definition: NB! Type 1 DM
Systemic metabolic disorder with a tendency to chronic
hyperglycemia Type 2 DM
Disturbances in fat, carbohydrate and protein metabolism Other specific types
Defect in insulin secretion and/or action
Complications: Gestational DM
Hyperglycemia, hypoglycemia and long term complications
Long-term effects of diabetes include:
retinopathy
nephropathy
neuropathy
Microangiopathy
Macroangiopahty

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Type 1 DM Type 1 DM
Mechanism: cell destruction, usually leading
to absolute insulin deficiency Markers for autoimmune mediated Type 1
Typically in younger patients DM:
Onset: days - weeks Pancreatic Islet cell ABs
Immune mediated or Idiopathic Insulin auto ABs
Glutamic acid decarboxylase (GAD)
These patients are prone to ketoacidosis,
coma and death.

Type 2 DM Type 2 DM
cell dysfunction 85% of diabetic patients
cell dysfunction
Disorders of insulin action and secretion
Disorders of insulin action and secretion
Insulin resistance and inadequate insulin Insulin resistance to peripheral tissues and inadequate
response to hyperglycemia insulin response to hyperglycemia
Interaction between genetic and environmental Interaction between genetic and environmental factors
factors Progressive condition
Progressive condition Can occur at any but, but typically in middle-aged to
elderly population
Typically in middle-aged and elderly population Often associated with obesity

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Other specific types of DM

Relatively uncommon conditions, causing DM
Specific genetically defined forms of DM
MODY
DM associated with other diseases/drugs
Pancreatitis
Cushing's syndrome
Glucocorticoids
Congenital rubella
Genetic syndromes like Downs syndrome

Gestational DM
Hyperglycaemia (glucose intolerance) with
onset or first recognition during pregnancy
Fetal complications
Adverse maternal outcomes
1st prenatal visit: Random, or fasting plasma
glucose, HbA1C
Screening with OGTT at 24 28 weeks
gestation

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Complications of DM
Hyperglycemia
Hypoglycemia of DM
Long term complications:
Including microvascular, macrovascular
Diagnosis of DM
Random plasma glucose (RG)
Fasting plasma glucose (FG)
Oral glucose tolerance test (OGTT)
HbA1C
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Diagnosis of DM
Classical symptoms and signs include polyuria,
polydipsia and weight loss
Glycosuria not diagnostic of DM
Demonstration of hyperglycemia
Intermediate hyperglycemia
Impaired fasting glucose
Impaired glucose tolerance
Diagnosis of DM: Random plasma
glucose
11.1 mmol/l if classic symptoms of
diabetes or hyperglycaemic crisis is present.
Random (casual) is defined as any time of day,
without regard to time of last meal.
The classic symptoms of hyperglycaemia include
polyuria, polydipsia and weight loss
Hyperglycaemic crisis refers to diabetic ketoacidosis
or hyperosmolar nonketotic hyperglycaemia.
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Diagnosis of DM: Fasting plasma
glucose
< 6.0mmol/L Normal
6.1-6.9 mmol/l Impaired fasting glucose
(IFG)
7.0 mmol/l - DM
Diagnosis of DM: Glycated
haemoglobin A1c (HbA1c)
DM 6.5%
Patient does not need to be fasted
Indication of average blood glucose
Understand limits of test:
Value < 6.5% does not exclude DM
Availability: Tertiary level test
Quality assurance/Standardization
Specific limitations factors that influence
measurement, populations not suitable for HbA1c
measurement NB!!!
Cost
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Diagnosis of DM: OGTT
Glucose load containing of 75 g anhydrous glucose
dissolved in 250 ml water ingested over five minutes
Plasma glucose test 2 hours after oral glucose load
PG: 7.8-11.0 mmol/l Impaired glucose tolerance
(IGT)
PG: 11.1 mmol/l - DM
GDM
HAPO study
International Association of Diabetes and
Pregnancy Study Groups (IADPSG)
recommends on HAPO data:
75g OGTT be performed
GDM diagnosed if any of the values for Fasting,
1hr or 2hr equalled or exceeded the diagnostic
threshold [ 5.1; 10; 8.5 mmol/l]
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Monitoring of Rx Microalbuminuria
Clinically: Symptoms 30 -300mg albumin in urine per 24h
Biochemically: Blood glucose concentrations, indicators
of glycaemic control <30mg/24h Normal
Self monitoring at home: Reagent strips/ blood glucose >300mg/24h overt proteinuria
meter.
Plasma glucose
Indicative of nephropathy, predictive of CVS
HbA1c risk
Microalbuminuria Not detectable with conventional dipsticks -
Plasma creatinine Use specialized dipsticks
Lipids Request albumin on 24h urine
Ketones: Urine/blood collection/Albumin creatinine ratio(ACR)
Not unique marker to DM marker of
increased endothelial permeability

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Ketoacidosis Insulin

Due to lack of insulin glucagon (counter

Glucose
regulatory hormones)
Effect: inhibition of glycolysis, glycogen
synthesis, promotion of glycogen breakdown,
increased rate of glucose production. H+ - acidosis
1st presentation of DM Type 1
Known patient with DM:
omitting insulin,
inadequate insulin dose, Ketones
increased insulin demand in trauma, acute illness

Ketone bodies Ketoacidosis Laboratory picture

Ketone bodies are acetoacetic acid, - Hyperglycemia
hydroxybutyric acid and acetone (acetone is Glycosuria
formed spontaneously from acetoacetate and Metabolic acidosis
cannot be further metabolized).
Ketones serum/urine
Ketones are formed in liver mitochondria
during the fasting state when insulin levels are Uraemia
low. Hyperkalemia
Peripheral tissue like heart and muscle convert Hypertriglyceridaemia
ketone bodies to acetyl CoA which can enter Hemoconcentration
the Krebs cycle and provide an alternative
source of fuel to glucose in times of food
deprivation.
Insulin blocks ketogenesis

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HHS Incretins
Hyperglycemic hyperosmotic state Gut-derived hormones
Severe hyperglycemia; BG >50mmol/L Members of the glucagon superfamily
Dehydration Released in response to nutrient -mainly
High plasma osmolality glucose and fat - ingestion
With or without ketones Stimulation of pancreatic insulin secretion in a
glucose-dependent manner
Play an important role in the local
gastrointestinal, but also whole-body
physiology

Incretin effect GLP-1 Not exactly... Glucagon

Oral glucose has a greater stimulatory effect
on insulin secretion than intravenous glucose
Higher insulin released in response to an oral
glucose challenge compared with an equal
intravenous glucose load
This effect is mediated by gastrointestinal
peptides namely the incretins
Glucose-dependent insulinotropic polypeptide
(GIP)
GLP-1
Responsible for 50 70% of total insulin
secretion of oral glucose administration

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GLP-1 Release
Proglugacon precursor processed - Multiple
proglucagon-derived peptides produced -cells of the
Produced from the proglucagon gene in L-cells pancreas:
stimulate gene
Glucose-
Release of
of the small intestine Food ingestion
GLP-1 transcription;
induced insulin
secretion.
secreted in response to nutrients insulin
secretion
GLP-1 levels are decreased in type 2 diabetes
GLP-1 regulation may be abnormal in type 1
diabetes
The role of GLP-1 in the treatment of type 1
diabetes is under investigation and GLP-1-
based therapies should not be used in
patients with type 1 diabetes.

Possible medical application Hypoglycemia

GLP-1 analogs are generating interest in the
treatment of type 2 diabetes
Exenatide and Liraglutide have received Food and
Drug Administration (FDA) approval
Antihyperglycemic actions - GLP-1-based
therapies used in the treatment of type 2
diabetes mellitus pts
The drug family consists of GLP-1 receptor (GLP-
1R) agonists (exendin, liraglutide) and DPP-4
inhibitors
Type 2 diabetes mellitus patients experience
improved glycemic control, weight loss and a
lowering of blood pressure (BP)
Other possible benefits include: promotion of b-
cell proliferation, reduced apoptosis
Neuroglycopenia at BG 3.0 -3.5mmol/L
Counter regulatory hormones/mechanisms to
respond at this level
Adrenergic response
Promotes glycogenolysis, gluconeogensis, lipolysis
Inhits insulin secretion
Counter regulatory hormones
Other mechanisms
insulin secretion inhibited
Hunger
Hepatic glucose output stimulated

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Hypoglycemia
Difficult to define a specific limit
Physiologic response to low blood glucose
concentrations varies among individuals

Diagnosis is based on clinical signs and

symptoms

Hypoglycemia Symptoms of hypoglycemia

Hypoglycemia - Plasma BG < 2.5 mmol/L + Hypoglycemia causes neurogenic (autonomic)
symptoms and neuroglycopenic symptoms.
Pathological hypoglycemia Whipples triad Neurogenic symptoms Neuroglycopenic
present tremor cognitive impairment
palpitations behavioral changes
anxiety/arousal psychomotor abnormalities
(catecholamine-mediated,
adrenergic)
sweating seizure
hunger coma
paresthesias (acetylcholine-
mediated, cholinergic)

Relief of symptoms after glucose

administration
Overview of hypoglycemia in adults ; Up to date version 19.3: January 2012

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Hypoglycemia Hypoglycemia in the adult

Adults: <2.8mmol/L Reactive
Drug induced
Childhood Postprandial
Alcohol
Whipples triad
Diagnosis: Non-reactive/Fasting
Insulinoma
Confirmation
Non-pancreatic neoplasms
Cause Hepatic/Renal disease
Endocrine disease
Alcohol induced fasting hypoglycemia
Sepsis
Inherited metabolic disease

Non-reactive/Fasting
Insulinoma
Non-pancreatic neoplasms
Hepatic/Renal disease
Endocrine disease
Alcohol induced fasting hypoglycemia
Sepsis
Inherited metabolic disease
Reactive
Drug induced (insulin, suphonylureas, B-
Adrenergic blockers)
Postprandial (typical in pts that underwnet gastric
surgery; 90 -150 min post 75g glucose load in
OGGT)
Alcohol can increase insulin release
Other inherited metabolic diseases

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Hypoglycemia in childhood Investigations in hypoglycemia

Premature/small for dates babies at greater risk low hepatic glycogen During hypoglycemic episode collect blood for:
stores
Transient neonatal hypoglycemia Plasma glucose (confirmation)
Hyperinsulinaemia Insulin (appropriate vs. inappropriate suppression)
Islet cell hyperplasis C-peptide (endogenous vs. exogenous insulin origin)
Insulinoma
Inherited metabolic disorders Sulphonylureas screen (excludes factitious causes)
Glycogen storage disease Ketones: urine/serum
Galatocaemia
Heriditary fructose intolerance Blood pH
Fatty acid B-oxidation defects Lactate
Other IGF-1 (actions resembles that of insulin binds to
Prematurity
Small-for dates
insulin receptor, tumour related hypoglycemia
Endocrine disorders possible due to excess production0
Starvation BEFORE ADMINISTRATING GLUCOSE!!
Drugs
Ketotic hypoglycaemia

Insulin Insulin
C-peptide C-peptide

Endocrine cause Insulinoma

Liver / kidney failure Sulphonylurea
Non-pancreatic islet cell tumours Insulin receptor antibodies

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Insulin
C-peptide

???Exogenous insulin

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