DISEASE OF METABOLISM AND

ENDOCRINE SYSTEM

COURSE NAME: INTERNAL MEDICINE

LECTURER: DR SULEIMAN DAHIR JIMALE

PREPARED BY: DR SULEIMAN DAHIR JIMALE 1

Diabetes Mellitus
DM is a clinical syndrome characterized by chronic
hyperglycemia and disturbance in carbohydrate, lipid and
protein metabolism.

The disease may result from defects in insulin secretion,

insulin action (resistance) or both.

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Diabetes mellitus (DM), is a group of metabolic disease in which there are high
blood sugar levels over a prolonged period.

Symptoms of high blood sugar include frequent urination, increased thirst, and
increased hinger.

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Diabetes is due to either the pancreas not producing enough insulin or
the cells of the body not responding properly to the insulin produced.

There are three main types of diabetes mellitus:

oType 1 DM

oType 2 DM

oGestational diabetes

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Type 1
Formerly known as insulin-dependent DM)

Usually occurs in childhood or early adulthood (age less than 30)

Patients are usually thin.

They require insulin for survival and develop ketoacidosis when

patients are not on adequate insulin therapy.

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This accounts for 10% of cases of DM.

Oral hypoglycemic agents will not be effective to lower the blood glucose level.

Type 1 DM is due to β-cell destruction, with absolute deficiency of insulin, which

is of multifactorial causes such as genetic predisposition, viral and autoimmune

attacks on the beta islet cells. It may be immune mediated or idiopathic.

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The following factors contribute:
1. Genetic susceptibility.
2. Inheritance.
3. Viral infection.
4. Pancreatic pathology.
5. Immunological pathology.

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Type 2
Formerly non insulin-dependent DM.

Usually occurs in people >40 years of age

Most (about 60%) of the patients are obese.

Type 2 DM occurs with intact beta islet cell function but there
is peripheral tissue resistance to insulin.

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There may be some decrease in insulin production or a hyperinsulin state.

These patients are not prone to develop ketoacidosis but may develop it
under conditions of stress.

Patients do not require insulin for survival at least in the earlier phase of
diagnosis.

The blood sugar level can be corrected by oral hypoglycemic agents.

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The exact cause unknown, following factors may be
responsible:
1. Genetics.
2. Environmental factors.
3. Pancreatic pathology.

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Gestational onset DM (GDM)
Is when diabetes onsets during pregnancy and resolves with
delivery.

These patients are at a higher risk for developing DM at a

later date.

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Comparison of Type 1 and Type 2 Diabetes
Feature Type 1 diabetes Type 2 diabetes
Onset Sudden Gradual
Age of onset Mostly in children Mostly in adults
Body size Thin or normal Often obese
Ketoacidosis Common Rare
Autoantibodies Usually present Absent
Endogenous insulin Low or absent Normal, decreased or increased
Prevalence 10% 90%
C-Peptide Absent Present

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Signs and Symptoms
The classic symptoms of untreated diabetes are:
Weight loss.
Polyuria (increased urination).
Polydipsia (increased thirst) and
Polyphagia (increased hunger).

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Symptoms may develop rapidly (weeks or months) in
Type 1 DM, while they usually develop much more
slowly and may be subtle or absent in type 2 DM.

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In addition they also include:
o Blurry vision.

o Headache.

o Fatigue.

o Slow healing of cuts and

o Itchy skin

Prolonged high blood glucose can cause glucose absorption in the lens of the
eye, which leads to changes in its shape, resulting vision changes.
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Complications of DM

Acute complications:
1. Diabetic ketoacidosis.
2. Hyperosmolar nonketotic coma (HONK)

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Diabetic ketoacidosis
Is a result of severe insulin insufficiency. It occurs in type 1
diabetes and may be presented manifestations.

Precipitating factors of DKA include insufficiency or

interrupted insulin therapy, infection, emotional stress, and
excessive alcohol ingestion.

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Hyperosmolar nonketotic coma (HONK)

Is a syndrome that occurs predominantly in patients with

type 2 diabetes and is characterized by severe hyperglycemia
in the absence of significant ketosis.

Precipitating factors include: Non compliance with treatment

plus in ability to drink sufficient water to keep up with urinary
loses.
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Chronic complications
Chronic complications of diabetes involve the macro-and
microvasculature, and are a major result of disease
progression. These complications reduce patients quality of
life, incur heavy burdens to the health care system, and
increase diabetic mortality.

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Microvascular disease of diabetes include:
oDiabetic nephropathy.

oNeuropathy.

oRetinopathy.

Macrovascular disease include contains: Coronary artery

disease, peripheral arterial disease and Stroke.

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Diagnoses
Some patients may be Asymptomatic mainly Type 2
patients and GDM Diagnosis is made incidentally
during routine medical checkup, ANC follow up etc.
Therefore it is advisable to screen patient for DM, if
following risk factors are present:

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o Obesity (BMI >25 kg/m2 ).

o First-degree relative with DM

o History of gestational DM or delivered a baby weighing more than >4kg ( 9 lb )

o Hypertensive.

o Hyperlipidemia HDL 250 mg/dl.

o History of impaired fasting glucose or impaired glucose tolerance glucose on prior

testing.

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 Criteria for the Diagnosis of Diabetes Mellitus:
Symptoms of diabetes plus random blood glucose concentration ≥11.1
mmol/L ( 200 mg/dL ) OR

Fasting plasma glucose of >126 mg/dl (7 mmol/L) OR

2-hour postprandial plasma glucose >200 mg/dl after a glucose load of 75

g ( during oral glucose tolerance test)

N.B. These criteria should be confirmed by repeat tests on a different day.

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Treatment
Goal of therapy:
oEliminate symptoms and prevent the complications of diabetes.

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A. Non pharmacologic Therapy
1) Diet therapy.

2) Exercise: has multiple positive benefits to diabetic patients including :

o Cardiovascular risk reduction

o Reduce blood pressure

o Maintain muscle mass

o Reduction in body fat and helps in losing weight.

o It is beneficial to both Type 1 and Type 2 patients

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Therefore regular exercise 20-30 minutes, aerobic exercise
such as jogging, walking, swimming etc 3 – 4 days is
recommended.

N.B Patients on Insulin treatment should be cautious to avoid

hypoglycemia

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3) Weight reduction.

4) Patient education: Involving patients in the their own

treatment plan essential.

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Areas of Patient Education:
o Patients should be made to understand DM is needs lifelong treatment and follow up

o Goal of treatment should be set together with the patient

o To avoid excess alcohol intake and, smoking o Benefit of weight reduction, diet and regular exercise

o Proper foot care

o Hypoglycemia causes , symptoms and simple first aid management

o Complications of diabetes

o Insulin injection technique

o Self glucose monitoring

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B. Pharmacologic therapy.
1. Insulin:
oType 1 DM patients must be started on insulin at the time of
diagnosis.
oThe average daily insulin requirement is approximately
0.3U/Kg/day (25 units /day) in a person with type 1 diabetes in
whom the production of endogenous insulin is assumed to be nil.

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Different preparations of insulin based on their
duration of action:

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Side effects:
The most serious complication of insulin is hypoglycemia.

Hypersensitivity, atrophy or hypertrophy of injection sites

may also occur, sometimes.

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B. Pharmacologic therapy Cont…
2. Oral hypoglycemic agents:
oThese groups of drugs are widely used in type 2 patients
whose hyperglycemia has failed to be controlled with
conservative measures.

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a) Sulfonylureas: stimulate pancreatic beta cells to secrete
insulin. Dose: Glyburide 2.5 to 20 mg PO or Glipizide 5 to 20 mg
PO

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b) Metformin:
oReduces blood glucose levels by improving hepatic and
peripheral tissue sensitivity to insulin without affecting the
secretion of insulin.
oMetformin is used as monotherapy or in combination with
sulfonylureas or insulin for type 2 DM.

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c) Alpha-glycosidase inhibitors:

Acarbose and Miglitol: are oral agents that reduce the

absorption of carbohydrates, thus reduce postprandial
hyperglycemia.

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d) Thazolidinediones: reduce insulin resistance and increase
peripheral glucose utilization.

These drugs include: Pioglitazone, Rosiglitazone.

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Hypoglycemia.
Hypoglycemia in the diabetic patient is caused by:
oOverdose of insulin or hypoglycemic agents.

oMissing of meal.

oStrenuous exercise

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Clinical manifestations
Early: one may feel the effects of sympathetic stimulation
such as cold sweat, tremor, hunger or palpitations.

Late: If early symptoms are neglected then symptoms of the

effect of hypoglycemia on the brain (Neurogenic
manifestations) such as dizziness, blurring, headache,
nightmares, and coma may occur.
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 Management
Any patient with diabetes losing consciousness should always be
considered hypoglycemic until proven otherwise by blood sugar
determination and should be managed by rapid IV administration of
glucose or PO/ NG tube administration of any concentrated sugar
solution.

Prolonged unconsciousness requires continuous 10% IV glucose

administration.
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END
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