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DIABETES MELLITUS
Chronic metabolic disorder associated with increase blood
sugar level secondary to reduced insulin or impaired
insulin utilization
Part of metabolic syndrome (patients with hyperuricemia,
hyperlipidemia, etc.)
Associated with cerebrovascular accidents, angiopathy,
microvascular/cardiovascular (ischemic heart disease)
disease, retinopathies, neuropathy (sensorimotor), and
the more dreaded renal complication (diabetic nepropathy
chronic renal insufficiency/renal failure); accelerated
atherosclerosis and hypertension
**random plasma glucose (aka random blood sugar [RBS]); fasting plasma
glucose (fasting blood sugar [FBS]); post-load glucose (post-prandial glucose
Etiologic Classification of Diabetes Mellitus [PPG]); OGTT (oral glucose challenge test [OGCT])
Type 1 (juvenile type) **OGTT: glucose is dissolved in 1 glass of water (to be consumed in
Beta cell destruction usually leading to absolute insulin 5 minutes) determine glucose level after 2 hours (blood glucose
deficiency should normally go down after 2 hours) if >200, possible
Immune-mediated, idiopathic diabetes.
Diabetic ketoacidosis (DKA) common **The above criteria should be confirmed by repeat testing on a
Type 2 different day. The 3-hour OGTT is NOT recommended for routine
May range from predominantly insulin resistance clinical use.
(peripheral resistance particularly the muscle) with relative
insulin deficiency to a predominantly secretory defect with
insulin resistance
DKA NOT common
Gestational DM (GDM)
Other Specific Types
Genetic defects of beta cell function
Genetic defects in insulin action
Diseases of the exocrine pancreas
Endocrinopathies*
Drug or chemical-induced*
Infections
Uncommon forms of immune-mediated diabetes
*usual causes
** impaired fasting glucose (IFG); impaired glucose tolerance (IGT)
** Patients with IFG and IGT are NOT immediately labeled as
diabetic; this only signifies that they are at risk for developing
diabetes in the future.
**OGTT/OGCT: 75 g glucose for non-pregnant and 100 g glucose for
pregnant check glucose level after 30 minutes, 1 hour, 2 hours,
and 3 hours
Laboratory Dx of DM
RBS, FBS
Post prandial blood sugar/ OGTT
Glycosylated Hb – monitors efficacy of treatment
Ketone – to detect DKA
Urine glucose – home monitoring tool (self-test)
Other tests to monitor DM complication
Renal function test: creatinine, Creatinine
clearance, BUN
Urine albumin, microalbuminemia: to check for
impending diabetic nepropathy
Lipid profile
Renal infection screen (urinalysis): DM patients
prone to renal infection
OGTT
Clinical significance: used as a reflex testing for impaired 2-
hour post-prandial test
gold standard or confirmatory test in diagnosing patients
with GDM
Patient preparation : * Ma’am did not discuss the details of this table.
diet of > 150 gm CHO for 3 days **In many laboratories, urine sample is collected at the same time
NO alcohol, unrestricted activity for 3 days as the plasma samples (OGTT).
NOT done after acute illness, surgery, emotional Advantage – correlation between any glycosuria and the
stress, trauma, pregnancy, inactivity due to corresponding plasma glucose levels
chronic illness, hospitalization Disadvantage – cost; another stress for the patient (4 urine
10 – 12 hrs fasting samples are also required together with 4 extractions of
AVOID oral diuretics, contraceptives phenytoin blood)
because they have hyperglycemic effect
Loading dose : Impaired Glucose Tolerance
Must be consumed within 5 min Higher than normal plasma glucose but lower than the
Adults = 75 gms diagnostic values for DM
Children = 1.75 gms / kg BW Precursor for Type II DM (may have preclinical DM)
Pregnant = 100 gms Only about 25% develop into type II and rest go back to
After drinking, instruct patient to sit down and normal depending on the person’s lifestyle
rest or NOT walk around too much. Patients are more susceptible to macrovascular diseases
Draw blood (i.e. atherosclerosis)
after an 8-hour fast; after extracting the FBS (1st Similar risk factors as DM II
blood extraction), give the glucose load.
nd
Extract another blood specimen at 30 (2 blood OGTT Clinical use
rd th
extraction), 60 (3 ), and 120 minutes (4 ) post Reflex testing for px with borderline FBS (110-140 gm/dl):
glucose challenge means that if the FBS is within this range, the next step in
Intrusive to the patient due to 4 blood the algorithm is OGTT.
extractions Adjunct to diagnose IGT and IFG (as a confirmatory test)
Gold standard for dx of gestational DM
OGTT Criteria
Plasma Glucose Plasma Glucose OGTT is NOT indicated in:
( mmol/L ) ( mmol/L ) Persistent fasting hyperglycemia (> 140 mg/dl )
0 min 120 min Persistent fasting normoglycemia(< 110 mg/dl )
Non-diabetic <6.1 <7.8 Px with s/sx of DM with FBS > 200 mg/dl (this is already a
Impaired Glucose 6.1-6.9 >7.8-11.1 diagnosis of DM so you do NOT need to confirm it with
Tolerance OGTT)
Diabetic >7 >11.1 Secondary DM
Evaluation of reactive hypoglycemia
dx of DM in children (because the reference values are
that of the adults)
GLUCOSE LEVEL
NORMAL Ancillary Tests
Urine Tests (Dipstick Method)
300
GLUCOSE
Glycosylated proteins
Glycosylated haemoglobin (HbA1c)
to monitor blood sugar levels for an extended Increased HbA1c levels in:
period of time Presence of HbF (fetal hemoglobin)
to monitor patient compliance to treatment Chronic renal failure
regimen Post splenectomy
to monitor adequacy of blood glucose control Iron deficiency anemia
stable; most important Hypertriglycerenemia
a form of fetal hemoglobin Alcohol, lead and opiate toxicity
HbA1c – LGI reference range 4.6-6.5%; 6% Salicylate treatment
indicates good control and level >8% indicates
action is needed Decreased HbA1c levels in:
glucose canNOT be dissociated from hemoglobin Shortened RBC life span particularly in hemolytic anemias
so HbA1c indicates cumulative glucose exposure Following transfusion
for the preceeding 2-3 months (3 months being Pregnancy
the life expectancy of a normal RBC) Ingestion of large amounts of Vit C/E
Glucose binds continuously and IRreversibly with Hemoglobinopathies
Hb during life span of RBC (120 days)
Disadvantage: affected by altered red cell Recommendations of the International Expert Committee
survival (canNOT be used in For the diagnosis of diabetes:
hemoglobinopathies, thalassemia, haemolytic The HbA1c is an accurate, precise measure of chronic
dse because of shortened RBC survival) glycaemic levels and correlates well with the risk of
If with good diabetic control, test HbA1c q6 diabetes complications
months; if poor control, test quarterly. It has several advantages over laboratory measures of
Fructosamine glucose
mirrors glycosylation of all serum proteins DM is diagnosed when HbA1c is ≥6.5 %. Diagnosis should
indicates previous 2-3 weeks glycaemic exposure be confirmed with a repeat HbA1c test. Confirmation is
used pregnancy/children in some sites not required in symptomatic subjects with plasma glucose
Glycosylated albumin levels >200 mg/dl (>11.1 mmol/l)
indicates previous several days glycaemic If HbA1c testing is not possible, previously recommended
exposure diagnostic methods (e.g., FBG or 2hPPG, with
not commonly used confirmation) are acceptable
HbA1c testing is indicated in children in whom diabetes is
Glycosylated HB (HbA1c) suspected but the classic symptoms and a casual plasma
Indicates average plasma glucose level for 6 to 12 weeks glucose >200 mg/dl (>11.1 mmol/l) are not found
Clinical use :
monitor diabetic px compliance Clinical implications
a lot of patients cheat blood glucose by HbA1c for diabetes diagnosis offers greater convenience
dieting for a week before they are and accuracy than glucose measurements and correlates
tested; a px canNOT cheat HbA1c well with
levels long-term complications
index of diabetic control (direct relationship of HbA1c may be too expensive for routine use in some parts
poor control and increased complication) of world
predicts development and progression of HbA1c may be influenced by haemoglobin traits and
microvascular complication precluded for people with conditions that affect red cell
Dietary preparation not required turnover (haemolytic anaemia, chronic malaria)
N: 4 – 8 % (*Ma’am said 4-6%) HbA1c not ‘gold standard’ for diabetes diagnosis, as no
Can estimate the mean daily glucose level single assay can define the relationship between glucose
mean daily carbohydrate (CHO) level in mg/dl = and vascular complications
10 x (HbA1c value + 4)
Interpretation :
Increased levels implies poor diabetic control
when FBS is < 110 mg/dl, HbA1c is normal in 96%
of cases
when FBS is 110-125 mg/dl, HbA1c is normal in
80% of cases
when FBS is > 126 mg/dl, HbA1c is normal in
>60% of cases
GESTATIONAL DIABETES
st
**Screening test is 2-hour postprandial glucose test (1 step). When
the result is abnormal, do reflex confirmatory testing (OGTT).
Renal testing in DM
Self-Monitoring blood glucose (SMBG) HYPOGLYCEMIA (*included in the ppt but not discussed)
Clinical classification:
People who take insulin should regularly self-monitor
• Drugs
blood glucose
Insulin, Sulfonylureas, Benzoic acid derivatives
Makes use of a point of care device (i.e. a refractometer)
(repaglinide), Nateglinide, Alcohol, Pentamidine, Beta-
For people with non-insulin treated type 2 diabetes testing
blockers, Quinine, Salicylates, Sulfonamides, Haloperidol,
is most useful if patients use the results to learn and alter
Propoxyphene, Para-aminobenzoic acid
behaviour, or medication.
• Hypoglycemia of infancy and childhood
“...SMBG is most useful if patients use the results to learn,
Hyperinsulinism, transient: Erythroblastosis fetalis,
as part of an overall diabetes education package….”
Beckwith–Wiedemann syndrome, uncontrolled diabetes
(mother), Persistent: Hyperinsulinemic hypoglycemia of
Other tests
infancy, Glycogen storage diseases, Hereditary fructose
Testing of LFTs (liver function test?) is recommended for px with DM
intolerance, Galactosemia, Defects in gluconeogenesis,
at diagnosis
Reye's syndrome, Deficiency of glucose transporters,
at the start of antidiabetic drug therapy
Impaired ketogenesis, Carnitine deficiency, Defects in
at any other time indicated by clinical judgement
mitochondrial function
**In patients with type 1 diabetes, intermittent checks for other
• Alimentary hypoglycemia
autoimmune conditions may be useful. This could include testing for
Post-gastric surgery
thyroid dysfunction or celiac disease.
• Idiopathic (functional) postprandial