1、Diabetes MellitusIntroduction Diabetes mellitus is a heterogeneous group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion,insulin action,or both.IntroductionThe chronic hyperglycemia of diabetes is associated with long-term damage,dysfunction,and failu
2、re of various organs,especially the eyes,kidneys,nerves,heart,and blood vessels.SymptomsPolyuriaPolydipsia(thirst)Weight lossWeaknessPolyphagiaBlurred visionRecurrent infectionImpairment of growthCriteria for diagnosis Criteria for diagnosis of diabetes of diabetes(WHO1999)Symptoms of diabetes +Casu
3、al plasma glucose 1.1mmol/l(200mg/dl)OrFPG 7.0mmol/l(126mg/dl)Or2-hPG 11.1mmol/lDiagnostic Criteria WHO1999IGT -FPG7mmol/L -2-h PG7.8mmol/L and 11.1mmol/LIFG -FPG6.1mmol/L and 7.0mmol/L Laboratory FindingsUrinary glucoseUrinary ketoneBlood glucose(FPG and 2-hPG)HbA1c and FA(fructosamine)OGTTInsulin/
4、CP releasing testClassification(1)Type 1 diabetes -cell destruction,usually leading to absolute deficiency Immune-mediated diabetes Idiopathic diabetesType 2 diabetes Ranging from predominantly insulin resistance with relative insulin deficiency to predominantly an insulin secretory defect with insu
5、lin resistanceClassification(2)Other specific types of diabetes Due to other causes,e.g.,genetic defects in insulin action,diseases of the exocrine pancreas,drug or chemical inducedGestational diabetes mellitus(GDM)diagnosed during pregnancy Etiologic classification of diabetes mellitus(1)I.Type 1di
6、abetes(-cell destruction,usually leading to absolute insulin deficiency)A.immune mediated B.IdiopathicII.Type 2diabetes(may range from predominantly insulin resistance with relative insulin deficiency to a predominantly secretory defect with insulin resistance)III.Other specific types A.genetic defe
7、cts of -cell function 1.Chromosome 12,HNF-1 (MODY3)2.Chromosome 7,glucokinase(MODY2)3.Chromosome 20,HNF-4 (MODY1)4.Mitochondrial DNA 5.Others B.Genetic defects in insulin action 1.Type A insulin resistance 2.Leprechaunism 3.Rabson-Mendenhall syndrome 4.Lipoatrophic disease 5.Others C.Diseases of the
8、 exocrine pancreas 1.Pancreatitis 2.Trauma/pancreatectomy 3.Neoplasia 4.Cystic fibrosis 5.Hemochromatosis 6.Fibrocalculous pancreatopathy 7.OthersEtiologic classification of diabetes mellitus(2)D.Endocrinopathies 1.Acromegaly 2.Cushings syndrome 3.Glucagonoma 4.Pheochromocytoma 5.Hyperthyroidism 6.S
9、omatostatinoma 7.Aldosteronoma 8.Others E.Drud-or chemical-induced 1.Vacor 2.Pentamidine 3.Nicotinic acid 4.Glucocorticoid 5.Thyroid hormone 6.Diazoxide 7.-adrenergic agonists 8.Thiazides 9.Dilantin 10.-Interferon 11.Others F.Infections 1.Congenital rubella 2.Cytomegalovirus 3.Others Etiologic class
10、ification of diabetes mellitus(3)G.Uncommon forms of immune-mediated diabetes 1.“Stiff-man”syndrome 2.Anti-insulin receptor antibodies 3.Others H.Other genetic syndromes sometimes associated with diabetes 1.Downs syndrome 2.Klinefelters syndrome 3.Turners syndrome 4.Wolframs syndrome 5.Friedreichs a
11、taxia 6.Huntingtons chorea 7.Laurence-moon-Biedl syndrome 8.Myotonic dystrophy 9.Porphyria 10.Prader-Willi syndrome 11.Others IV.Gestational diabetes mellitus(GDM)Patients with any form of diabetes may require insulin treatment at some stage of their disease.Such use of insulin dose not,of itself,cl
12、assify the patient.Type 1 DMGenerally 7.010.0HbA1c(%)6.28.0Blood pressure(mmHg)130/80-160/95BMI(kg/m2)Malefemale25242726 27 26Total cholesterol(mmol/L)1.11.1-0.90.9Triglycerides(mmol/L)1.52.2 2.2LDL-cholesterol(mmol/L)4.4ManagementEssentials of managementMonitoring of glucose levelsFood planningPhys
13、ical activityTreatment of hyperglycemia2.Monitoring of Glucose LevelsBlood glucose levels -before each meal -at bedtime Urine glucose testingUrine ketone tests(should be performed during illness or when blood glucose is 20mmol/L)3.Food PlanningWeight control.50-60%of the total dietary energy should
14、come from complex carbohydrates.20-25%form fats and oils.15-20%from protein.Restrict alcohol intake.Restrict salt intake to below 7g/d.4.Physical ActivityPhysical activity play an important role in the management of diabetes particularly in T2DM.Physical activity improves insulin sensitivity,thus im
15、proving glycemic control,and may help with weight reduction Do sparingly avoid sedentary activitiesDo regularly participate in leisure activities and recreational sportsDo every day adopt healthy lifestyle habits5.Drug TreatmentIf the patient is very symptomatic or has a very high blood glucose leve
16、l,diet and lifestyle changes are unlikely to achieve target values.In this instance,pharmacological therapy should be started without delay.TreatmentSulphonylureasBiguanides-Glucosidase inhibitorsThiazolidinedionesGlinidesInsulinCombination therapy1.SulphonylureasChlorpropamideTolbutamideGlibenclami
17、deGlipizideGliclazideGliguidone Glimepiride2.BiguanidesMetforminPhenformin Buformin 3.-Glucosidase inhibitorsAcarboseVogliboseMiglitol4.ThiazolidinedionesRosiglitazonePioglitazoneCiglitazone 5.GlinidesNategliniderepaglinide6.InsulinInsulin is the most efficacious pharmacologic treatment for patients
18、 with diabetes6.InsulinIndication PreparationTherapy Adverse reactionManagement Algorithm for Overweight and Obese T2DMDiet Exercise and weightcontrol Failure Add biguanide,TZD or -glucosidase inhibitorsFailure Failure Combine two of these or add sulphonylurea or glinideAdd insulin or change to insu
19、linCheck adherance at each stepManagement Algorithm for Non-Obese T2DMDietExerciseand weightcontrolFailure FailureFailureAdd sulphonylurea,biguanide,-glucosidase inhibitors or glinideCombine sulphonylurea or glinide with biguande and/or -glucosidase inhibitors and/or add TZDAdd insulin or change to insulinCheck adherance at each step
