36yo women with DM. Fasting BG = 12mmol/L [Fasting PG>7mmol/L; 2hr PG/random PG with classic S/S>11.1mmol/L; A1C>6.5%
DM crisis
~dehydration (dec skin tugor, dry axillae & oral mucosa, low JVP, tachycardia)
Diabetic ketoacidosis (more often from Type 1)
~fulminant (<24hr) polyuria, polydipsia, lethargy, N/V, abdominal pain, dyspnea (kussmaul) & delirium, fruity odor
~Lab: glucose>/=14mmol/L; urine ketones + or serum beta-hydroxybutyrate>3mmol/L; high anion gap metabolic acidosis (pH<7.3/HCO3-<18mmol/L)
Hyperglcaemic hyperosmolar state (HHS) (often type 2)
~insidious onset (days) of osmolar symptoms (polyuria, polydipsia), lethargy, delirium, obtundation, focal neuro sign (hemiparesis/hemianopsia, seizures), marked hypovolaemia/dehydration
~Lab: glucose>33mmol/L; hyperosmolarity .320mmol/L; no acidosis
Secondary causes
Endocrine
Pancreatic disorders
Gestational DM (diagnosed at 2nd-3rd trimester & not clearly type 1/2 DM)
~Diagnosis: 1hr 50g glucose load test followed by a 3hr 100g OGTT for those screened positive
Iatrogenic
Critical illness
Haemochromatosis
~Liver dz (hepatomegaly, elevated LFT -> fibrosis & cirrhosis)
~Skin pigmentation, weakness/lethargy, arthralgia
~reduced insulin & c-peptide secretion (due to selective beta-cell damage)
Chronic pancreatitis
Pancreatectomy (Whipple)
Cystic fibrosis
~insulin insufficiency
~annual OGTT. treat with prandial insulin therapy
Steroid induced hyperglycemia
Total parenteral nutrition
Glucose containing drip
Stress hyperglycaemia
Primary diabetes
~polyuria, polydipsia, nocturia, blurred vision
Type 1 DM
~Insulin deficiency secondary to autoimmune beta destruction, weight loss (hypovolemia & catabolism)
~young (<25yo), thin, other autoimmune dz
~fulminant presentation, FHx (+ in 50%), Anti-islet & GAD autoAb, high c-peptide levels
~RF: same as type 2
Type II DM
~insulin resistance, late phase: beta-cell failure secondary to hyperglcarmia
~older (>40yo), metabolic syndromes, overweight
~insidious onset, FHx (+ in 90%)
~RF: BMI>23; age>45, meds (GC, thiazide diuretics, atypical antipsychotics), prior GDM
Complications
Cardiovascular - angina, HF, AMI
~artheriosclerosis, CAD
Cerebrovascular (TIA, stroke)
Peripheral vascular dz - limb claudication, ulceration
~peripheral vascular obstruction -> gangrene, limb loss
Retinopathy
~inc floaters, dec visual acuity non-correctable with refraction in macula edema, curtain falling with vitreous bleed, glaucoma, cataracts
Neuropathy - diabetic foot
~socks & gloves stocking
Cushingoid habitus
~dec libido, obesity/weight gain. round face, menstrual changes, hirsutism, HTN, ecchymoses, lethargy, dorsal fat pad, truncal obesity, buffalo hump, abdominal striae, osteoporosis
Acromegaly
~coarse facial features (aged), macroglossia (w deep furrows), spade-like hand, deep voice, diaphoresis, frontal bossing
Pancreatic endocrine neoplasm
~insulinoma -> whipple triad (low BG, hypoglycemic symptoms (lethargy, syncope, diplopia), resolution of symptoms after normalization of glucose levels
Treatment:
~dietary mod & excercise (>150min/week) - goal of 5-10% weight loss
~Metformin (if not contraindicated-severe renal/hepatic insufficiency)
~Insulin therapy (for newly diagnosed TIIDM & marked symptomatic/elevated BG
~ + 2nd oral agent (e.g. GLP-1, basal insulin) if non-insulin monotherapy does not achieve A1C target (<8%) within 3-6 months
~ + 3rd oral agent (if still not achieved after 3 months)
~Swop to injectibles if 3 months of triple therapy still fail
Monogenic diabetes syndrome
Neonatal diabetes
~onset in 1st 6 month of life. Transient (defect on ZAC/HYAMI imprinting) v.s. perm (AD defect in Kir6.2 subunit of beta-cell K channel. Treatment with sulfonylureas)
Maturity-onset diabetes of the young
~impaired insulin secretion with minimal/no defects in its action
~atypical diabetes & multiple FHx w atypical diabetes
Treatment:
~multiple (3-4 injections/day) dose basal & prandial insulin. educate them to match insulin dose to carb intake, premeal BG & anticipated activity
~or continuous subQ insulin infusion
~Pharmaco: Metformin
~Pancreas & islet cell transplant (last line)
Nephropathy
~Progressive proteinuria