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36-year-old female lawyer is diagnosed with diabetes mellitus when her…
36-year-old female lawyer is diagnosed with diabetes mellitus when her fasting blood glucose on an annual health screening comes back 12mmol/L
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Investigations
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Require history and P/E to assess characteristics of onset of diabetes (asymptomatic lab finding or symptomatic polyuria and polydipsia), nutrition and weight history, physical activity, CVS risk factors, Hx of diabetes-related complications, hypoglycaemic episodes
Measure also fasting lipid profile, liver function tests, urine albumin excretion, serum creatinine, serum TSH (in type 1 DM
Management
Diet, physical activity and behavioural therapy
Lifestyle changes to achieve modest and sustained weight loss. Greater weight loss produces greater benefits, and can reduce BP, improve LDL and HDL cholesterol, and reduces requirement of meds to control blood glucose, BP and lipids.
Pharmacotherapy
Carefully review patient's concomitant medications and try to minimise or provide alternatives for medications that promote weight gain (e.g. atypical antipsychotics like clozapine, risperidone etc; antidepressants TCAs, SSRIs, MAOIs; glucocorticoids; OCPs)
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Patient education
Instruction on nutrition, physical activity, optimising metabolic control and preventing complications. For patients who are overweight or obese BMI above 25, major emphasis on lowering caloric intake and increasing physical activity to achieve weight loss
Improving glycaemic control induced by weight loss is associated with partial correction of insulin resistance and impaired insulin secretion.
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Evaluation of microvascular and macrovascular complications, attempts to achieve near-normal glycaemia, minimise cardiovascular and other long-term risk factors
Routine eye exam to screen for diabetic retinopathy and correctable visual impairment; routine foot examination for peripheral neuropathy, ulceration and necrosis; screen for increased urinary albumin excretion in case of diabetic nephropathy; screen for coronary heart disease (BP, fasting lipids, smoking Hx)
Pharmacotherapy
Enhances insulin secretion via electrophysiological mechanisms (i.e. binding ATP dependent K+ channels)
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Glinides: Nateglinide, Repaglinide
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Public health approaches, encouraging healthy diet and increased exercise, weight loss
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For most patients, start with metformin at the time of diabetes diagnosis, along with consultation for lifestyle intervention (see management). Start with 500mg once daily with evening meal and if tolerated, add a second 500mg dose with breakfast. Then dose can be raised as needed slowly.
For patients contraindicated to metformin, can use shorter-acting sulfonylurea (glipzide) which balances glucose-lowering efficacy, universal local availability and low cost with the risk of hypoglycaemia and weight gain.
Diagnosis of DM
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When two different tests results are above diagnostic thresholds, Dx of DM is confirmed
When two different tests have discordant results, the test whose result is above the diagnostic cut point (usually the fasting plasma glucose or 2-hr post-challenge glucose) should be repeated!