Diabetes Mellitus
p. 1 of 5
Definitions: Diabetes mellitus is a chronic metabolic disorder characterized by hyperglycemia due to defective insulin secretion, insulin action or both. Chronic hyperglycemia is associated with significant long-term sequelae particularly: damage, dysfunction and failure of organs, especially: kidneys, eyes, nerves, heart and blood vessels. There is no known cure for diabetes.
Dysglycemia is blood glucose (BG) that is abnormal without a defining threshold.
Classic Symptoms:
· polyuria (↑ urination),
· polydipsia (glucose in urine),
· unexplained weight loss
Classification of Diabetes:
Type 1 result of pancreatic beta cell destruction; prone to ketoacidosis. Includes
autoimmune cases.
Type 2: ranges from insulin resistance with relative insulin desufficiency to secretory
defect with resistance.
Gestational: glucose intolerance during pregnancy
Other Specific Types: wide variety of uncommon conditions.
Diagnosis:
Fasting (>8 hrs) Plasma Glucose: FPG ≥ 7.0 mmol/L
Random Plasma Glucose ≥11.1 mmol/L & symptoms of Diabetes
Oral Glucose (75g) Tolerance Test, 2h Plasma Glucose ≥ 11.1 mmol/L
A confirmatory lab glucose test must be done, in the absence of hyperglycemia with
acute metabolic decompensation..
Diagnosis of Impaired Fasting Glucose (IFG) or Impaired Glucose Tolerance (IGT)
FPG 6.1 – 6.9mmol/l or 2hPG in a 75g OGTT 7.8 - 11.0mmol.L
Diagnosis of Diabetes FPG ≥ 7.0mmol/l or 2hPG in a 75g OGTT ≥ 11.1mmol.L
Glucosated Hemoglobin (HgbA1C) is essentially glucose bound to hemoglobin and gives a 3 month picture of past glucose control. HgbA1C has a lack of standardization and this precludes its use in the diagnosis of diabetes.
Prediabetes: Metabolic Syndrome:
leads to a significant risk of developing diabetes and CVA:
· Abnormal abdominal obesity,
· hypertension,
· dyslipidemia (high cholesterol and/or triglycerides),
· insulin resistance and dysglycemia
(Reference: NCEP ATP III Criteria [JAMA.2001;285:2486-2497])
B.McLaughlin.DiabetesMellitus.Nov2004.WD.disc..EditedOct05
Diabetes Mellitus p. 2 of 5
Metabolic SyndromeRisk Factor / Defining Level (≥ 3 risk determinants)
FPG (Fasting Plasma Glucose) / ≥ 6.1 mmol/L
BP (Blood Pressure) / ≥ 130 / 85 mmHg (Diabetes goal: ≤130/80)
TG (Triglycerides) / ≥ 1.7 mmol/L
HDL-C: Men (High Density Lipoprotein)
Women / < 1.0 mmol/L
< 1.3 mmol/L:
Abdominal Obesity: Men
Women / Waist Circumference: >102 cm (40”)
> 88 cm (35”)
Risk Factors for Type 2 Diabetes (Key: * = associated with metabolic syndrome)
Ø Age ≥ 40 yrs.
Ø 1st Degree relative with diabetes
Ø Aboriginals, Hispanic, S. Asian, Asian, African descent
Ø IGT or IFG*
Ø Complications associated with Diabetes
Ø Vascular disease*
Ø GDM history
Ø Macrosomic infant history
Ø Hypertension*
Ø Dyslipidemia*
Ø Overweight*
Ø Abdominal Obesity*
Ø Polycystic Ovary Syndrome*
Ø Acanthosis nigricans* (‘tanned’ lower legs)
Ø Schizophrenia (3x higher than general population)
Ø Other: genetic defects of Beta cells / insulin action; diseases of pancreas; endocrinopathies; infections (congenital rubella, cytomegalovirus, etc.); drug or chemical induced; genetic syndromes
Screening for Diabetes:
Adults: screen for risks annually.
Obese children ≥ 10 yrs. old with risks, screen biannually.
FPG every 3 years if ≥ 40yrs. with no other risks; Earlier / more frequently if more risks.
Pregnant women: screened at 24-28 wks gestation; if multiple risks, in 1st trimester;
Urine dipstick test at each prenatal visit screen for glycosuria & other problems.
Symptoms of HypoglycemiaNeurogenic (autonomic) / Neuroglycopenic
Trembling Palpitations
Sweating Anxiety
Hunger Nausea
Tingling / Difficulty concentrating Confusion
Weakness Drowsiness
Vision Changes Headache
Difficulty speaking Dizziness
Tiredness
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Diabetes Mellitus p. 3 of 5
Hypoglycemic reactions:
Mild: Autonomic symptoms; client can self-treat.
Moderate: Autonomic and neuroglycopenic symptoms; client can self treat.
Severe: Requires assistance. Unconsciousness may occur. PG <2.8 mmol/L
Hypoglycemia Treatments:
Give carbohydrates – avoid over treatment.
For Mild to Moderate hypoglycemia:
15g glucose (monosaccharide) or sucrose (white sugar) increases PG in 20 min.
Milk and orange juice are slower.
Glucose gel is quite slow and must be swallowed.
For Severe Hypoglycemia: Conscious – 20g glucose orally, test in 15 min. and re-treat
with 15g oral glucose if PG <4.0
Unconscious at home: Glucagon IM/SC; Call EMS (IV D50W should be given).
To prevent repeated hypoglycemia, have client eat usual snack or meal for that time of day or if meal is >1 hr away, eat a snack including 15g carbohydrate and a protein source.
Hospitalized patients on insulin and at risk for hypoglycemia should have IV access readily available or a PRN order for glucagon.
Risks for Hypoglycemia:
· Prior episode of severe hypoglycemia
· Current low HgbA1C (<6.0%)
· Hypoglycemia awareness
· Long duration of diabetes
· Autonomic neuropathy
· Adolescence
· Preschool-age unable to detect/treat hyppoglycemia
Diabetes Life Style Modifications:
BP < 130 mmHg systolic and < 80 mmHg diastolic (<130/80)
10% weight loss over 6 months with maintenance via exercise &/or calorie reduction
(500kcal/d deficit can lead to expected weight loss of 1-2kg/month).
For BMI >30, bariatric surgery may be considered.
Exercise: 150 min./week on 3 non-consecutive days; rhythmic repeated and continuous
movement of the same large muscle groups for at least 10 min. at a time.
Sedentary patients should have a preliminary exercise ECG stress test.
DM Type 2 - ≥ 4 hrs./week, moderate intensity (50-70% maximum heart rate)
DM Type 1 – resistance exercise 3x/week
Long term complications of diabetes mellitus can be reduced by tight glycemic control.
The risk of severe hypoglycemia can be 3x higher with intensive therapy, thus
Normoglycemia* may not be desirable for some clients. (*FPG/preprandial [before eating] 4.0-6.0; PG 2hr. post-prandial [after eating] 5.0 – 8.0);
HgbA1C ≤6.0% may not be appropriate for some (eg children ≤ 12 yrs; elderly)
The emotional and social impact of hypoglycemic reactions may restrict clients’ efforts in
glycemic control. B.McLaughlin.DiabetesMellitus.Nov2004.WD.disc..EditedOct05
Diet Control: Diabetes Mellitus p. 4 of 5
· Canada’s Guidelines for Healthy Eating
· Eat a variety of foods
· Emphasize whole grain breads, cereals and products, fruits and vegetables
· Choose lower fat dairy products, leaner meats & foods prepared with little/no fat.
· Limit sodium & caffeine
· Limit alcohol (1-2 drinks/d; ♂<14/wk; ♀<9/wk); intake 2-3 hrs after supper can cause morning hypoglycemia
· Carbohydrates 50-55% of energy
· Protein 15-20% of energy
· Fat <30% of energy (saturated fats & trans fatty acids <10% of energy); include monosaturates & foods rich in polyunsaturated omega-3 fatty acids & plant oils.
· Choose low glycemic index foods
Diabetes Delivery of Care:
§ Multi- & interdisciplinary team approach: Person with diabetes & their family, Family MD& NP, Specialist, Nurse Educator, Dietician.
§ Initial and ongoing needs-based diabetes education to enhance self-care.
§ Support persons should be taught how to give glucagon IM/SC.
§ BP should be measured every diabetes visit.
§ Individuals with diabetes should be screened regularly for psychological problems, depression & anxiety, using open-ended questioning re: stress, social support, beliefs about their disease & behaviours that impair glycemic control.
§ Adults with diabetes should receive an annual influenza vaccine and considered for pneumococcal immunization; children should receive both.
§ Cardiovascular Risk reduction: pharmacological intervention; lifestyle changes; reduced weight; optimize BP; lipid control; glycemic control; smoking cessation.
§ Annual screening for diabetic neuropathy: Type 2, and Type 1 – test people that are post-pubertal with diabetes ≥5yrs., using a 10-g monofilament or test for vibration sensation at the great toe. Carpal tunnel syndrome may present.
§ Annual (at least) foot exam for structural abnormalities, neuropathy, vascular disease, ulceration and infection beginning at puberty.
§ Those at high risk for ulceration & amputation require foot care education, proper footwear, foot trauma avoidance, smoking cessation, & early referrals.
§ A fasting lipid profile (Total Cholesterol, HDL-C, Triglycerides & calculated LDL-C) is done every 1-3 yrs; ≤18yrs. are screened if other risk factors present.
§ Annual serum Creatinine levels; those with albuminuria, every 6 mos.
§ Infections should be treated aggressively by experts.
§ Endoscopic eye exam for retinopathy: Type 1 - annually; Type 2 -every 1-2 yrs.
§ All adult males should be periodically screened for erectile dysfunction
§ Adolescent & young adult females regularly screened for eating disorders using nonjudgemental questions about weight / shape concerns, dieting, binge eating & insulin omission for weight loss.
§ After 2-3 months of lifestyle management without reaching glycemic targets, pharmacological interventions usually are initiated. B.McLaughlin.DiabetesMellitus.Nov2004.WD.disc..EditedOct05
Pharmacological Interventions Diabetes Mellitus p. 5 of 5
Drug Class : OralAlpha-glucosidase inhibitor
Acarbose (Prandase®)
Biguanide
Metformin (Glucophage®, generic)
Insulin Secretagogues Sulfonylureas: -gliclazide (Diamicron®, Diamicron® MR, generic)
-glimepride (Amaryl™)
-glyburide (Diabeta®, Euglucon®, generic) (chlorpropamide & tolbutamide rarely used)
-nonsulfonylureas nateglinide (Starlix®) repaglinide (GlucoNorm®)
Insulin Sensitizers (TZDs) pioglitazone (Actos®) rosiglitazone (Avandia®)
Combined rosiglitazone and metformin (Avandamet™)
Antiobesity Agents Orlistat (Xenical®) gastrointestinal lipase inhibitor, or
Sibutramine (Meridia®) norepinephrine and serotonin reuptake inhibitor).
Drug Class: Injectible Insulin
Type / Names / Appearance / Onset / Peak / Duration
Rapid-acting analogue / Humalog® (insulin lispro) NovoRapid® (insulin aspart) / clear / 10-15 min. / 60-90 min / 4-5h
Fast-acting / Humulin®-R Novolin® ge Toronto / clear / 0.5 – 1 hr. / 2-4 hrs / 5-8h
Intermediate-acting / Humulin® L Humulin® N Novolin® ge NPH / cloudy / 1-3 h. / 5-8h / up to 18h
Long-acting / Humulin® U / cloudy / 3-4h / 8-15h / 22-26h
Extended Long-acting analogue / Lantus® (insulin glargine) –approved/not available / 90 min. / 24h
Premixed: fixed ratio of % rapid / fast acting to % intermediate acting / Humalog® Mix25™ Humulin® (20/80, 30/70) Novolin® ge (10/90, 20/80, 30/70, 40/60, 50/50) / cloudy
Cardiovascular risk reduction: ACE Inhibitor (for BP and kidney protection; not in
pregnancy), antiplatelet therapy (ASA) (helps prevent embolisms), statin or
fibrate (helps reduce cholesterol or triglycerides)
Blood Pressure Control: 1st-ACE inhibitor, 2nd-ARB for co-existing LVH, 3rd-
cardioselective beta blocker, 4th-thiazide-like diuretic, or 5th-long acting CCB.
Painful neuropathy: tricyclic antidepressants or anticonvulsants
Reference: The Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2003; 27(suppl 2).
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