Please enable JavaScript.
Coggle requires JavaScript to display documents.
36YO female lawyer diagnosed with diabetes mellitus (DM) (Etiology…
36YO female lawyer diagnosed with diabetes mellitus (DM)
Investigations
Test HbA1c to determine how long pt has had hyperglycemia (last 2-3 months glucose control). May be falsely low in anemic patients, or falsely high in uremic patients.
Use HbA1c to check for control in the future. If >10% => severely uncontrolled. Treatment: insulin therapy with lifestyle intervention as initial Rx.
Liver function tests and renal panel to check for severe renal/hepatic insufficiency. If present, metformin is contraindicated as it may be associated with lactic acidosis. Use metformin with caution in those with eGFR < 45ml/min/1.73m2, cease usage if eGFR <30ml/min/1.73m2.
C-peptide proteins as marker of beta-cell fx => high levels imply T2DM. Low levels may be burnt out T2DM which requires insulin.
Etiology
Overweight/obese => Primary DM. Other sx: insidious presentation; +ve family hx in 90%. Other sx: thirst; polyuria; weight loss; blurry vision
Cushingoid (moon-like facies; buffalo hump; striae on abdomen) and acromegalic features (coarse facial features; macroglossia; spade-like hand) => Endocrine or pancreatic endocrine neoplasms (RARE). Other sx: hypertension
Cystic fibrosis; chronic pancreatitis; pancreaticotomy (e.g. Whipple); hemochromatosis => Pancreatic disorders. Other sx of hemochromatosis: skin hyperpigmentation; unexplained fatigue; +ve family hx of iron overload
Morning sickness, missed periods, sexually active => pregnancy/gestational DM.
Recent surgery/hospitalization => steroid-induced hyperglycemia; TPN; glucose-containing drip.
Treatment
Co-morbid conditions
Exenatide (GLP1 agonist) not recommended in T2 diabetes patients with hx of pancreatitis.
Class III/IV cardiac failure: use metformin with care. Long-acting sulfonylureas are not recommended.
TZDs are contraindicated in patients with acute coronary syndrome, IHD and all classes of heart failure.
If metabolic control sub-optimal => use insulin. May be initiated as a bedtime dose of intermediate-acting or long-acting insulin with maintenance of oral agents during the day.
If obese/overweight => weight reduction to be attempted gradually (0.25 to 1kg/week). Weight loss of 5-10% of body weight is realistic. Recommended that total calories from fat intake be kept to <30% of total caloric intake in diabetic patients.
Oral glucose lowering targets should be started if glycemic targets are not achieved in a timely and appropriate manner.