References: [20] [26] [27] [28]. Weight reduction, exercise , medical nutrition therapy, self-management education. The drug of choice is metformin. Add a third oral antidiabetic drug , nightly basal insulin , or injectable GLP-1 receptor agonist. Oral antidiabetic drugs should be avoided in patients undergoing surgery or suffering from severe illness.
Instead, insulin therapy should be initiated! References: [7] [20]. References: [6] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39]. Strict glycemic control is crucial in preventing microvascular disease. References: [1] [7] [40] [41] [42] [43] [44] [45] [46]. We list the most important complications. The selection is not exhaustive. Diabetic nephropathy is a major cause of end stage renal disease ESRD. Microalbuminuria is the earliest clinical sign of diabetic nephropathy.
The extent of albuminuria correlates with the risk of cardiovascular disease! Early antihypertensive treatment delays the progression of diabetic nephropathy! References: [2] [20] [48] [53] [54] [55] [56] [57]. References: [58] [59] [60] [61] [62] [63]. References: [58] [64] [65] [66] [67] [68] [69] [70].
References: [67] [71] [72] [73]. References: [7]. References: [3] [4] [74] [75] [76] [77] [78] [79]. Interested in the newest medical research, distilled down to just one minute? Expand all sections Register Log in.
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Diabetes mellitus. Summary Diabetes mellitus DM describes a group of metabolic diseases that are characterized by chronic hyperglycemia elevated blood glucose levels. Association with other autoimmune conditions Hashimoto thyroiditis Type A gastritis Celiac disease Primary adrenal insufficiency Type 2 Hereditary and environmental factors Association with metabolic syndrome Risk factors Obesity , high-calorie diet High waist-to- hip ratio visceral fat accumulation Physical inactivity First-degree relative with diabetes Ethnicity Hypertension Dyslipidemia History of gestational diabetes References: [6] [7] [8] [9] [10] Classification Classification according to the WHO and American Diabetes Association ADA [11] Type 1 : formerly known as insulin -dependent IDDM or juvenile-onset diabetes mellitus Autoimmune type 1A LADA : Latent autoimmune diabetes in adults , a variant of diabetes characterized by a late onset of type 1 autoimmune diabetes that is often mistaken for type 2 diabetes.
The cleavage of proinsulin precursor molecule of insulin produces the C-peptide connecting peptide and insulin , which consists of two peptide chains A and B chains.
Action : Insulin has a variety of metabolic effects on the body, primarily contributing to the generation of energy reserves and glycemic control. Carbohydrate metabolism : Insulin is the only hormone in the body that lowers the blood glucose level. Over the course of the disease, insulin resistance progresses, while insulin secretion capacity declines. After a period of impaired glucose tolerance with isolated postprandial hyperglycemia , diabetes manifests with fasting hyperglycemia.
Alternatively, a pathological fasting plasma glucose FPG test, oral glucose tolerance test OGTT , or hemoglobin A1C HbA1C test establishes the diagnosis see table below If hyperglycemia is high enough to suggest but not confirm a diagnosis of DM, two similar test results, either from the same sample or from a separate test sample, will confirm the diagnosis.
Monitoring complications Regular monitoring of weight, abdominal circumference, blood pressure, blood lipids, renal retention parameters creatinine , electrolytes , injection site in patients receiving insulin therapy Yearly eye exam type 1 : after 5 years with diabetes mellitus or after the age of 11 years ; more frequently in patients with abnormal findings or diagnosed retinopathy Annual urine testing for microalbuminuria Foot exam for neuropathy and ulcers ; advise patients to wear appropriate footwear and avoid injury Routine screening for psychosocial problems, including signs of depression and cognitive impairment Pneumococcal vaccines.
Treatment algorithm Description General measures Weight reduction, exercise , medical nutrition therapy, self-management education Monotherapy The drug of choice is metformin. Total daily requirement of insulin On average, the body requires 40 USP units of insulin daily.
Morning hours: 2 units insulin , lunchtime: 1 unit , evening hours: 1. The initial total daily dose TDD of insulin should be 0. After beginning insulin treatment, there is often a temporary reduction in exogenous insulin demand. Type 2 diabetes Residual endogenous insulin production is augmented with exogenous insulin , depending on the extent of insulin resistance which in turn depends on the level of obesity. The TDD of insulin should be 0. Acute Hyperglycemic crisis : undiagnosed or insufficiently treated diabetes mellitus may result in severe hyperglycemia , potentially culminating in a coma Hyperosmolar hyperglycemic state HHS Diabetic ketoacidosis DKA Life-threatening hypoglycemia : secondary to inappropriate insulin therapy Long-term Macrovascular disease More common in patients with type 2 diabetes Pathophysiology: The major determinants are metabolic risk factors , which include obesity , dyslipidemia , and arterial hypertension.
Hyperglycemia may be less related to the development of macrovascular disease. Other manifestations Sweat gland dysfunction associated with heat intolerance Pupillary dysfunction Risk of hypoglycemia due to absence of hormonal counterregulation secretion of cortisol , glucagon , and catecholamines. Major risk factors include peripheral sensory neuropathy, autonomic neuropathy , microvascular changes , as well as macrovascular disease. Secondary infection of foot ulcers may lead to cellulitis and acute or chronic osteomyelitis.
Diabetic neuropathic arthropathy Charcot foot : deformation of joints and bones Tarsus and tarsometatarsal joints most commonly affected Coexisting ulcers common Acute: swelling, warmth, erythema Chronic: painless bony deformities, midfoot collapse , osteolysis , risk of fractures Prevention Glycemic control Regular foot examinations Self-monitoring and proper foot care Treatment of foot ulcers Surgical debridement Regular wound dressing Mechanical offloading: fitting of therapeutic footwear or total contact cast Antibiotic therapy if foot ulcers become infected Interventional or surgical revascularization : in patients with underlying peripheral artery disease Amputation if all else fails or severe life-threatening complications arise.
Gestational diabetes mellitus Pregestational diabetes mellitus Definition Impaired glucose tolerance diagnosed during pregnancy ; associated with an increased risk of maternal and fetal morbidity Diabetes mellitus type 1 or type 2 that is present prior to pregnancy , which is associated with a significantly increased risk for maternal complications during pregnancy and delivery, and congenital malformations! In the first trimester , insulin sensitivity increases and there is a tendency towards hypoglycemia.
In the second and third trimesters, hormonal changes trigger progressive insulin resistance that results in hyperglycemia , particularly after mealtimes. References Khardori R. Type 2 Diabetes Mellitus. Updated: January 12, Accessed: February 13, American Diabetes Association. Clinical Diabetes. Type 1 Diabetes Mellitus. Updated: September 30, Nutritional considerations in type 1 diabetes mellitus.
In: Post TW, ed. Caution should be used in patients with liver or kidney dysfunction or in those who often skip meals. Two drugs are available in this class: Nateglinide and repaglinide; both are available in generics.
The glinides have a similar mode of action as sulfonylureas; however, glinides have a more rapid onset of action and shorter duration, so they are a good option for patients with erratic timing of meals. Also, the hypoglycemia risk is lower than with sulfonylureas; however, glinides have a similar-to-lower risk of weight gain after initiating therapy. Caution must be used in patients with liver dysfunction.
Dosing is before meals. This drug class competitively blocks the enzyme alpha glucosidase in the brush borders of the small intestine, which delays absorption of carbohydrates absorbed in the mid and distal portions of the small intestine instead. They primarily target postprandial hyperglycemia but do it without causing hypoglycemia. GI complaints, such as bloating, abdominal cramps, flatulence, and diarrhea, are the main side effects. Use should be avoided in patients with severe hepatic or renal impairment.
Dosing must occur before carbohydrate-containing meals. Two drug products are marketed, and both are available in generics. Incretin-based therapies are available as injections glucagon-like peptide-1 [GLP-1] receptor agonists or oral formulations dipeptidyl peptidase-4 [DPP-4] inhibitors. These therapies differ slightly in their mechanisms of actions, as described in the following sections. All incretin-based medications carry an increased risk of acute pancreatitis.
Patients must be warned about this risk and be advised to stop taking these medications and to seek medical evaluation if acute abdominal pain develops. These medications should not be given to individuals who have a history of medullary thyroid carcinomas or have multiple endocrine neoplasia type 2. This restriction is based on increased incidences of thyroid C-cell tumors observed with these medications in murine models.
So far, no increased risk in humans has been observed. Nevertheless, these patients should not use incretin therapies. The GLP-1 agonists are administered by injection and stimulate insulin secretion and suppress glucagon secretion after meals in a glucose-dependent manner. Exenatide is a synthetic form of exendin 4, a hormone found in the saliva of the Gila monster, which mimics GLP GLP-1 is produced in the small intestine.
It stimulates insulin secretion and inhibits glucagon secretion and hepatic glucose production in a glucose-dependent manner. It also delays gastric emptying and suppresses appetite through central pathways. It primarily decreases postprandial blood glucose levels; however, a moderate reduction in fasting blood glucose levels also occurs. Due to its delaying effects on gastric emptying, the major side effects are GI complaints of nausea, vomiting, and diarrhea.
Hypoglycemia does not occur when exenatide is used as monotherapy or with metformin, but it does occur when exenatide is combined with a sulfonylurea. Benefits include weight loss up to 2 to 3 kg in the first 6 months and up to 5. Dosing is twice daily by subcutaneous SC injection at least 60 minutes before the 2 main meals. The initial starting dose is 5 mcg.
If this dose is tolerated, titrate after 1 month to 10 mcg. It is administered once a day as a subcutaneous injection from its pen device. Timing is independent of meals. Half-life is about 13 hours. Its beneficial effects and side effects are similar to those of exenatide, but it may be slightly more powerful in its actions. The initial dose is 0. If there are no side effects, the dose is increased to 1. For most patients, the dose will be increased to 1. Liraglutide has shown cardiovascular protection in a clinical study.
Exenatide also is available as a once per week SC injection extended-release exenatide. If a dose is missed, it should be administered as soon as possible, provided that the next dose is scheduled 3 or more days later. Albiglutide is a newer GLP-1 analog that has a half-life of 4 to 7 days.
Dulaglutide is another long-acting GLP-1 analog. Dosing is 0. Dipeptidyl peptidase-4 DPP-4 is a cell membrane protein that rapidly degrades GLP-1 and glucose-dependent insulinotropic polypeptide.
Suppression of DPP-4 leads to higher levels of insulin secretion and suppression of glucagon secretion in a glucose-dependent manner. The DPP-4 inhibitors act primarily on postprandial blood glucose levels, but reductions in fasting glycemia are also seen. These agents are generally well tolerated, with the most common side effect being headache. An increase in nasopharyngitis also has been seen. Benefits include being weight-neutral and not causing hypoglycemia either as monotherapy or when combined with metformin or thiazolidinediones.
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View revision history Report problem with Article. Citation, DOI and article data. Foster, T. Diabetes mellitus. Reference article, Radiopaedia. Vascular , Hepatobiliary , Gastrointestinal. URL of Article.
Educational portal of. Diabetes Mellitus. About Monitoring Managing Drugs. What is Diabetes? Causes of Diabetes. Types of Diabetes. Diabetes is classified into various types based on its causes. Classification and observations of the different forms of diabetes mellitus More.
References: Diagnosis and classification of diabetes Mellitus April , Jennifer Jiang, Dr. Shuchismita Dutta; Reviewed by Drs. Stephen Schneider and Stephen K.
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