DIABETES MELLITUS

30th May 2021

 OUTLINE

• Prevalence of diabetes mellitus.

• Classification and risk factors.
• Pathophysiology and symptoms.
• Complications.
• Screening and diagnosis.
• Treatment

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 • Killing
• Handicapping • Money
• Complications • Prevalence

Why Diabetes?
International Diabetes Federation – 10th Edition, 2021

With 10.9 Million

diabetics Egypt is
ranked in the 10th
Position among the
world

The IDF Diabetes Atlas 10th Edition 2021 (http://www.diabetesatlas.org/)

 Diabetes Kills
Overall, 75% of patients with
diabetes die from
cardiovascular disease1

1-Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences.
 WHO States Diabetes

Diabetes is a metabolic disorder of multiple

etiology, characterized by chronic hyperglycemia
with disturbances of carbohydrate, fat, and
protein metabolism resulting from defects in
insulin secretion, insulin action, or both.

6 Definition by the International Diabetes Federation(IDF)/ World Health Organization (WHO)

 01 Type 1 diabetes

02 Type 2 diabetes

Classification
03 Gestational diabetes mellitus

04 Specific types

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 •Type 1 diabetes;

•Less common. It predominantly occurs in children and young people.

•It is caused by beta-cell destruction (mostly immune-mediated) and absolute insulin deficiency.

•Symptoms develop over days to weeks, Including :Polyuria Polydipsia- Weight loss –Tiredness- Blurred

Vision

•May present with very high blood sugar and diabetic ketoacidosis: reduced consciousness/coma (this is

life threatening). Refer if clinical suspicion of type 1 diabetes in newly diagnosed patient to ER/consultant

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 •Type 2 diabetes;

•Due to progressive loss of β-cell leading to decrease in insulin secretion on

background of insulin resistance, it affects about 90% of patients with diabetes, It
is commonly associated with those who are overweight/obese.

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 •Gestational diabetes;
•Arises in 2–5% of pregnancies, usually resolves at end of pregnancy
•Risk factor for type 2 diabetes later in life

•Specific types;
•Due to other causes monogenic diabetes ,drug induced DM

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 Risk factors of diabetes mellitus;

1-Overweight/obesity. Body mass index ≥ 25 (kg/m2 ). Or waist

circumference (waist level is half way between bottom of ribs
and top of pelvis): Men ≥94cm, Women ≥ 80cm.
2-Hypertension or cardiovascular disease.
3- Frequent infections; particularly skin infections (diabetes
suppresses immune system).

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 4- Drugs that cause high blood glucose: e.g. oral steroids,
some anti retrovirals, antipsychotics (courses over 1 month)

5- History of gestational diabetes. Refer to Ob/ Gyna if

pregnant. Check FBG 4-12 weeks after delivery.

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 6- History of pre-eclampsia, dys lipidaemia and polycystic ovarian
syndrome.

7- Family history of diabetes (parent, child, brother, sister).

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 Pathophysiology of DM

Defective polymorphonuclear function → infection

↑
Hyperglycemia → glucosurea → polyurea → dehydration
Insulin lack ↓
Hyperosmolality
Proteolysis → weight loss → muscle wasting →
polyphagia
Lipolysis → free fatty acid release → ketosis → acidosis
 Symptoms of Acute Hyper-Glycemia
• Polyuria: excessive urination due to the body’s attempt to remove excess
glucose; the urine contains elevated levels of glucose

•Polydipsia: excessive thirst and drinking to combat the dehydration

produced by increased urination

•Polyphagia: excessive eating

•Weakness and fatigue occur due to protein and fat depletion; it can also
be due to fluid loss and electrolyte imbalance

15 Guyton, 2006, 2. kasper, 2005

 Co-morbid depression; often seen with diabetes and may present as
fatigue
Blurred vision; hyperglycemia-related changes in the water content of the
lens of the eye affect vision
Frequent superficial infections; and slow healing of minor skin trauma

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• DIABETES IS ADISEASE OF DISABLING AND FATAL COMPLICATIONS
 DM Complications
Strock

Macrovascular

Microvascular

Peripheral vasclar
disease
Your Aim in treatment is to Provide a Good Quality of Life for this Patient
 Clinical Impact of Diabetes Mellitus Micro-vascular & Macro-vascular
complications

A 2- to 4-fold
The leading cause
increase
of new cases of
In cardiovascular
ESRD
disease/events

Diabetes

The leading cause of The leading cause of

new cases of blindness Non-traumatic lower
in adults 20–74 years extremity
amputations
ESRD=end-stage renal disease
Adapted from WHO. Available at: http://www.who.int/dietphysicalactivity/publications/facts/diabetes/en/print.html. Accessed
February 6, 2009; American Diabetes Association. Diabetes Care 2004;27(suppl 1):S65–S67; American Diabetes Association
Diabetes Care 2004;27(suppl 1):S79–S83; American Diabetes Association Diabetes Care 2004;27(suppl 1):S84–S87.
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 Chronic Complications Of Diabetes

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 Screening

screen all people above age of 40 regardless

of symptoms. If normal repeat in 3 years.
Screen all people who have risk factors for
diabetes annually.

.
 • Test all people (at any age) with symptoms of the classical triad of
diabetes: polyuria, polydipsia, and polyphagia or if unexplained weight
loss

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Components of the Comprehensive Diabetes Medical Evaluation.

Comprehensive Medical Evaluation and Assessment of Comorbidities:

Standards of Medical Care in Diabetes – 2022 . Diabetes Care 2019;42(Suppl. 1):S34-S45
History in a patient with diabetes

Type of diabetes
History regarding illness
Glycemic control/Drug
history

Personal History Complications

History
Diabetes education

Family History

Social History
 Diabetes Diagnostic Criteria

Diabetes Diagnostic Criteria;

Random
2 hour glucose Fasting glucose HbA1c
Condition blood
(mg/dl) (mg/dl) %
glucose

Normal <140 <100 <5.7 ≤200

140-
Prediabetes 100-125mg/dl 5.7–6.4
199mg/dl

DM ≥200 ≥126 ≥6.5 ≥200

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 Pre diabetes;
Is not a disease but represents a higher risk for
developing diabetes, all such people need
intensive lifestyle intervention and annual
checking of HbA1c or FBG.
If no improvement consider metformin for some
people at high CV risk ≥30% (using non-diabetic
chart) or if obese with BMI≥35
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Classification and Diagnosis of Diabetes:
Standards of Medical Care in Diabetes - 2021. Diabetes Care 2019;42(Suppl. 1):S13-S28
 Newly diagnosed type 2 diabetes

Provide patient counseling on diabetes for all

patients:
Ask about ideas, concerns, and expectations and
discuss lifestyle changes. This is the most
important part of diabetes care.
-

28 DeFronzo RA. Diabetes 2009;58:773–795

 Once diagnosis confirmed perform baseline tests:

1. Weight, general urine examination, lipid profile, kidney function tests, liver profile,

TSH if symptoms of hypothyroidism, ECG, diabetic foot examination and fundus

examination.

2. Check blood pressure: if ≥140/90mmHg for two readings begin with ACE inhibitor

(unless contraindicated). Do cardiovascular risk assessment.

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 3. Start metformin (unless contraindicated) because it protects cardiovascular

system as well as reducing blood sugar. If over 40 years soon after diagnosis

start statin for primary cardiovascular protection (if liver profile normal).

4. Check the patient every month to see how much they understand regarding

their diagnosis of diabetes, and their lifestyle changes. Check blood sugar at

each visit or after 3 months if using HbA1c (gives average over 3 months)

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Algorithm of management of diabetes mellitus in PHC centers (1st line)
 Management of type 2 diabetes

Control Cholesterol:

- Eat healthy diet, exercise regularly, and take

lipid-lowering therapy (statins) if needed

- Lose Weight: Maintain healthy weight and

normal BMI. To lose weight, you need to burn

more calories than you eat.

according to Janka HU, 1992

 - Manage Blood Pressure:

- Achieve BP<140/90mmhg in most cases

- Lose weight;

maintain healthy weight and normal BMI . To lose weight you need to

burn more calories than you eat

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 - Reduce blood sugar ;

- achieve HbA1c<7%

- Control smoking :
- Quit smoking completely, not only reduce the consumption
(amount & frequency), as there is no safe lower limit of
tobacco use

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- Eat Better:
- Follow a diet that consists of fruits, vegetables, whole grains,
low-fat dairy products, poultry, fish, and nuts. Try to limit
sugary food and drinks, fatty or processed meats, and salt.

- Get Active:
Try to get at least 150 minutes (2 hours and half) per week of
moderate aerobic exercise (example: 30 minutes of brisk walking
5 times per week)

according to Janka HU, 1992

T2D management is more than just HbA1c control
Microvascular
disease
(kidney, nerves, >50%
eyes) develop microvascular disease
within 10 years1
Patients
with T2D 54%
MI increased risk of non-fatal MI (median 5.5
are at years) compared to those without T2D2
increased
risk of: 72%
Stroke increased risk of ischemic stroke (median
5.5 years) compared to those without T2D2

33%
Heart failure increased risk of hospitalization for heart
failure (at 4 years) compared to those without
T2D3
• HbA1c = glycated hemoglobin; MI = myocardial infarction; T2D = type 2 diabetes.

• 1. Litwak L et al. Diabetol Metab Syndr. 2013;5:57. 2. Shah AD et al. Lancet Diabetes Endocrinol. 2015;3:105-113. 3. Cavender MA et al. Circulation. 2015;132:923-931.
UKPDS : Glycemic Control Reduces Complications
Epidemiological extrapolation showing benefit of a 1% reduction in mean HbA1c

21% Deaths related to diabetes*

Microvascular complications (eg,

37% kidney disease and blindness)*
HbA1c

1% 14% Heart attack*

Amputation or fatal peripheral

43% blood vessel disease*

*P<.0001
**P=.035 12% Stroke**
Stratton IM et al. UKPDS 35. BMJ 2000; 321: 405–412
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Strictly for internal use only
Pharmacological management
Different oral anti-diabetic medication;
Medication How to start mechanism advantages Possible adverse
events
Metformin Start with 500 mg Decrease hepatic Extensive experience GI symptoms, vitamin
twice or 850 mg once glucose production No hypoglycemia B12 defeciency, use
per day after meal and Multiple other Inexpensive with caution or dose
then titrate the dose non-insulin-mediated adjustment for CKD,
weakly to reach 2000 mechanisms lactic acidosis (rare)
mg/d
SGLT2is Dapaglifozin start Blocks glucose No hypoglycemia, Genital and UTI
Dapagliflozin with 10 mg/d reabsorption by the decrease weight- infections, polyuria,
Empagliflozin Empaglifozin start kidney, increasing decrease blood volume depletion
with 10 mg/d and glucosuria pressure, effective for /hypotension/
titrate the dose to 25 all stages of T2D with dizziness, dose
mg/d if needed preserved GFR adjustment
/avoidance for renal
disease, risk DKA
(rare), expensive
 Medication How to start mechanism advantages Possible adverse
events

DDP4I 50 mg twice daily Glucose dependent: No hypoglycemia Genital and UTI

Insulin secretion Weight neutral infections, polyuria,
vildagliptin Glucagon secretion Well tolerated volume depletion
/hypotension/
dizziness, dose
adjustment
/avoidance for renal
disease, risk DKA
(rare), expensive

SUs Glimepiride: start Glucose dependent: Extensive experience Hypoglycemia,

from 1 up to 4mg/d Insulin secretion decrease decrease weight,
Glimepiride Gliclazide: start with Glucagon secretion Microvascular risk uncertain
Gliclazide 60 MR and titrate up Inexpensive cardiovascular safety,
to 120 mg/d Titration dose adjustment/
is based on biweekly avoidance for renal
pattern disease- high rate of
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secondary6/5/2023
failure
 Management of diabetes mellitus (2nd line)
• .

Apply the management algorithm for T2DM

• If HbA1c not at target after the previous lines, it is

preferred to:
• Add a basal insulin and titrate the dose every 3 days till
reaching the fasting target.
• Then add bolus insulin or shift to premixed insulin if further
intensifications,
• In case if basal insulin is not available shift to premixed
insulin from the start with some modifications in oral
treatment
Blood sugar control
Pre-prandial Post HbA1c
prandial
Target 80-130mg/dl Less than if
180mg/dl fit/healthy;≤7
%
If frial;≤8%

If blood sugar is above these levels (try not to change therapy based on
a single reading) OR if complications develop:
Review lifestyle: what changes can still be made.
Check compliance: are they taking their tablets regularly? Avoid causing
hypoglycemia
 Treatment of diabetes mellitus complications;

Hypoglycemia Ask about hypoglycemia symptoms (sweating, weakness, feeling dizzy, looking
pale, getting confused and unconscious). Check patient and family know what to
do. Can cause accidents in drivers: advise check blood sugar and eat before driving
or during long journey

Nephropathy High levels of creatinine or reduced eGFR and proteinuria. Refer to an internist.
Treatment should be with ACE inhibitor regardless of BP. Monitor renal function
carefully as ACE inhibitors can also cause renal failure

Retinopathy Ensure ophthalmoscopy to check for diabetic retinopathy every 1 year. In

retinopathy tighter sugar control may slow progression. Check for cataract: surgery
only if impairing ability in everyday activities

42 05/06/2023
Diabetic Foot Examine feet and check understanding of foot care at every consultation: proper
footwear, nail cutting, treatment of calluses. A full assessment using monola-
ment and checking foot pulses should be carried out annually. Ask about
reduced sensation caused by peripheral neuropathy, neuropathic (burning) pain.
If foot pulses absent, ulcers or deformity refer to secondary care.

Ask about: bloating/nausea/vomiting after meals, sudden diarrhea at night,

Autonomic erectile dysfunction, no warning signs (sweating, dizziness, tingling lips,
palpitations, feeling shaky, feeling hungry) when getting hypoglycemia (very
Neuropathy serious in drivers). If found, improve blood sugar and BP control, encourage
lifestyle change.
 Diabetic emergency
Severe hypoglycemia
-If blood sugar <50mg/dl, Give the
patient a sugary drink or 1-2teaspoons
of sugar.
-If unconscious ,requires rapid
treatment (give 20-30 mls of 50%
glucose (dextrose) IV over 1-3 minutes)
and refer immediately to hospital.
-If<70 mg/dl and more than one episode
in a week refer to specialist for review of
treatment
- Make sure the patient knows how to
recognize and prevent in the future
Severe hyperglycemia
(DKA) and (HHS) are potentially life-
threatening emergencies.
-Symptoms and signs of DKA and HHS
include: nausea, vomiting and
abdominal pain.
-Severe cases of DKA can present with
Kussmaul’s breathing. Patients can be
alert but also in stupor or coma
regardless of symptoms.
-Patients with HHS typically present
with altered consciousness (stupor or
coma).
-If blood sugar >300 mg/dl regardless of
symptoms, or ≥ 270 mg/dl with
symptoms, refer immediately to
hospital. Start rehydration.
When to refer to higher level of care
URGNT (same day referral to ER):
• If plasma glucose ≥300 mg/dl, test the urine for ketones: if ketones present refer to ER.
• Suspicion of ketoacidosis or hyperosmolar hyperglycemia.
• Hypoglycemia unresolved by treatment.
• Clinical suspicion of Type 1 diabetes in newly diagnosed patient, symptoms or signs of ischemic heart
disease and stroke.
• Recent deterioration in vision.
• Blood pressure >200/110 mmHg.
• Blood pressure >180/110 mmHg with headache, shortness of breath, blurred vision, changed mental
state, nausea, vomiting, reduced urine output, anuria or eGFR 130/80 mmHg
 Non-emergency referral to specialist;

Glycemic treatment goal is not achieved despite adherence to lifestyle measures and medication
(at highest tolerated dose) .

-More than one episode of hypoglycemia in a week refer to specialist for review of treatment

-Rising creatinine or reducing e GFR and proteinuria .

-Symptoms and signs of peripheral vascular disease .

-Blood pressure >130/80mmhg despite treatment with two medications .

-Total cholesterol> 310mg/dl .

46 6/5/2023
 My name is Pat Sweitzer
“I was first diagnosed as pre-diabetic in my late 40s.
My Dr prescribed me Metformin.

I didn’t take it seriously and continued my life normally

with no follow up.

I never thought of what was going to happen.

Now I’m 70 years old.
I suffer from heart problem, lost both of my legs and
part of my vision.”
I Blame Myself For That

I wish I could Turn Back Time and VERIFY the consequences

“I marvel that society would
pay a surgeon a large sum of
money to remove a person’s
leg- but nothing to save it.”

- George Bernard Shaw

Thank You

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