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This lecture is sponsored by a grant from the Delta Dental of Iowa Foundation IDA Annual
Conference Guest Lecture Series.
Diabetes Essentials 2011
Richard LeBlond, MD, MACPChief Quality Officer
Professor, Internal MedicineUniversity of Iowa Health Care
Learning Objectives
• Appreciate the challenge of diabetes from the patient’s perspective
• Differentiate type 1 from type 2• Understand insulin action• Understand complications of diabetes• Know the major classes of medications• Know the side effects of each class• Recognize hypoglycemia as a serious
complication arising during dental care
Diabetes Incidence in Childhood
What is Diabetes?Insufficient insulin activity
• Defined by the blood glucose level• The definition is arbitrary
– Fasting glucose >125 mg/dL– 2 hour post meal glucose > 200 mg/dL– Any glucose > 200 mg/dL– Glycohemoglobin > 6.5%
• Two predominant causes– Decreased insulin levels: type 1– Resistance to insulin action: type 2
Insulin
• Insulin is produced by the beta cells in the islets of the pancreas
• Small amounts of insulin are necessary to sustain life
• Insulin is necessary for the metabolism of carbohydrates
• Insulin acts predominantly on three tissues– Fat cells: take up glucose, convert to fatty acids, and
store energy as triglycerides – Muscle cells: take up glucose and store as glycogen– Liver: take up glucose and store as glycogen; stop
gluconeogenesis (making glucose from amino acids)
Causes of Diabetes
• Type 1: destruction of pancreatic islet cells– Autoimmune, usually childhood onset; genetic
predisposition; probable viral trigger– Non-immune destruction: acute and chronic
pancreatitis; hemochromatosis• Type 2: resistance to insulin action
– Genetic factors– Obesity: decreased adipocyte responsiveness to
insulin– Maturity Onset Diabetes of the Young (MODY):
abnormal insulin signaling– Corticosteroids & stress hormones: cortisol (Cushing
syndrome), growth hormone (acromegaly), epinephrine
Type 1 Diabetes Absolute Insulin Deficiency
• Incompatible with life• Ketoacidosis without insulin• Exogenous insulin is the only treatment• Usually young and thin• No family history of diabetes• Common causes of death:
– Ketoacidosis– Hypoglycemia– Kidney failure– Heart attack
Type 2 DiabetesResistance to Insulin Action
• Gradual onset and progression over years• Strong family history• Usually overweight or obese• Diagnosis in middle age (this is changing
rapidly)• Many treatment options• Long survival even without treatment• Common causes of death:
– Heart attack– Kidney failure
• Blood sugar <50 mg/dL associated with brain dysfunction and can lead to death
• Type 1 diabetics more susceptible • Medication overdose: insulin or sulfonylureas• Taking medication but not eating, or unable to
eat• Taking medication and exercising strenuously• Symptoms
– Autonomic response: shaky, sweating, hunger, agitation
– Neuroglycopenic symptoms: confusion, lethargy, coma
• Treatment: oral glucose, glucagon, iv glucose
Hypoglycemia
• Occurs in type1 diabetics with frequent episodes of mild-moderate hypoglycemia
• Blunted autonomic reflex responses to hypoglycemia
• Only neuroglycopenic symptoms occur• Inability to think clearly (judgment is the first to
go) leads to inappropriate, ineffective or no response
• Greatly increased risk of death• Absolute avoidance of hypoglycemia for several
months restores responsiveness
Hypoglycemia Unawareness
Long Term Complications of Diabetes Microvascular
• Damage to the small arterioles becomes manifest in specific organs
• Retinopathy: leading cause of blindness in US• Neuropathy:
– loss of protective sensation in the feet and legs– Autonomic neuropathy: loss of cardiovascular and
gastrointestinal autoregulation
• Nephropathy: loss of functional nephron mass leading to kidney failure. Leading cause for ESRD and dialysis in the US
• Microvascular complications are slowed or prevented by tight glucose control (Hb A1c < 6.5%)
• Accelerated atherosclerosis of the major arteries• Myocardial infarction: heart attack risk is the same as
someone who has had an MI• Stroke: strong cofactor with hypertension• Peripheral vascular disease: strong cofactors are
smoking and male gender• Tight glucose control (Hb A1c < 6.5%) does not have an
advantage over good control (Hb A1c 7.5%)• Prevention strategy is to manage all risk factors:
smoking, blood pressure (< 130/80), LDL-C (<70 mg/dL), exercise, weight loss
Long Term Complications of Diabetes Macrovascular
Other Complications of Diabetes
• Increase with blood sugars > 200 mg/dL• Mucocutaneous fungal infections:
– Oral candidiasis– Vulvovaginal candidiasis
• Periodontal disease• Poor wound healing• Wound infections• Urinary tract infections• Skin and soft tissue infections
MANAGEMENT:Goals, Objectives &Tools
• Goals: – the long term outcomes desired by the patient
and the physician
• Objectives: – the objective easily measurable way points
marking progress towards the goals
• Tools:– techniques, medications and other
interventions used to achieve the objectives
Long-term Goals
1. Life Goals– Family– Employment– Avocations
2. Medical Goals-Prevent microvascular disease
-Decrease risk for macrovascular disease
-Prevent hypoglycemic complications
-Prevent the 5 D’s: death, disability, depression, dependency, destitution
Long-term Objectives
• Meaningful clinically
• Meaningful to the patient
• Objective
• Measurable
• Easily assessed by the patient
• Transparent: easily interpreted
Long-term Objectives
1. Normal function
2. No severe hypoglycemia
3. Hemoglobin A1c ≤ 7%
4. Maximum glucose <180 mg/dL checked 1 ½ to 2 hours after meals
Long-term Objectives
1. Normal function
2. No severe hypoglycemia
3. Hemoglobin A1c ≤ 7%
4. Maximum glucose <180 mg/dL checked 1 ½ to 2 hours after meals
Prioritized
Tools
1. Education
2. Diet
3. Glucose monitoring
4. Exercise
5. Medications
6. Devices
7. Doctors: exams, other labs
Tools
1. Education
2. Diet
3. Glucose monitoring
4. Exercise
5. Medications
6. Devices
7. Doctors: exams, other labs
Priority
Non Blood Sugar ObjectivesGaede P, et al. Effect of a multifactorial intervention on mortality in type 2 diabetes. N
Engl J Med 2008;358:580-91
1. BP < 130/80, lower is better: whatever it takes2. Lipid control, TC, LDL-C, TG: statin3. Diet:
-total calories-low carbohydrate diet
4. Obesity-diet, drugs, surgery-progressive weight loss, weight target
5. Exercise: rehab, PT, 10,000 steps daily6. Preventive Care: foot exam, immunizations, etc7. Manage albuminuria & CKD: ACE-I, BP control8. Mood, depression impairs management: ? SSRI
Modern Insulin Management:All Type 1 and some Type 2 patients
• Optimal insulins are synthetic & humanized• Basal insulin: very long acting
– Given daily, often in the evening– Humanized long acting: glargine (Lantus®), detemir
• Prandial insulin: very short acting insulins– Given with meals– Humanized very short acting: lispro (Humalog®), aspart,
glulisine
• Correction dose insulin– Lower glucose elevated above premeal target level– Given 30-60 minutes before meals– Humanized very short acting insulins
Other Drugs for Type 1 and Type 2
• Glucagon: – antagonizes insulin effect for rapid reversal of
hypoglycemia
• Older Insulins: suboptimal treatment choices, but less expensive– Animal derived intermediate acting: NPH,
Lente– Animal derived short acting: Regular– Fixed dose mixtures: 70/30 (70% NPH, 30%
Regular)
Drugs To Treat Type 2 Diabetes
• Injectable:– Insulin– Incretin (GLP-1) agonists
• Oral– Metformin– Sulfoylureas– TZDs: thiazolidinediones– DPP4 inhibitors– Gut absorption blockers– Meglitinides
Metformin
• Drug of first choice for type 2 diabetes• Generic and low cost• Twice daily dosing• Increases insulin effect• Decrease liver glucose production• Increases peripheral glucose uptake• Does not cause hypoglycemia• Does not cause weight gain• Side effects:
– Diarrhea– Lactic acidosis, rare
Sulfonylureas
• Older agents
• Inexpensive
• Long acting
• Stimulate insulin release by beta cells
• Side effects– Weight gain– hypoglycemia
Meglitinides
• Repaglinide, neglitinide
• Increase insulin release by a different mechanism than sulfonylureas
• Fast and short acting
• Taken before meals to lower post prandial glucose rise
• Side effects– hypoglycemia
Incretin (GLP-1) mimetics
• Two available: exenatide (Byetta®)• Injectable• Once daily• Expensive• Used alone rarely causes hypoglycemia• Does not cause weight gain• Side effects
– Nausea is very common (> 40%)– Slowed gastric emptying
DPP4 Inhibitors
• Oral once or twice a day
• Two drugs available: sitagliptin, saxagliptin
• Newer, expensive, second line
• Inhibit breakdown of incretins
• Do not cause weight gain
• Do not cause hypoglycemia
• Side effects: few
Thiazolidinediones
• Oral, intermediate duration, once or twice a day• Increase sensitivity to insulin action• Two drugs in class: pioglitazone (Actos®),
rosiglitasone (Avandia®)• Do not cause hypoglycemia• Cause weight gain• Side effects
– Fluid retention and heart failure– Possible increased risk of MI
Second Line Drugs
• Alphaglucosidase inhibitors (acarbose and others)– Blocks carbohydrate digestion– Slows glucose absorption– Used in combination with metformin– Flatulence and diarrhea
• Lipase inhibitors: orlistat (Xenical®)– Block fat digestion– Diarrhea
Hypoglycemia:Which patient should concern you?
• Type 1 on insulin
• Not obese
• History of hypoglycemia (high risk for hypoglycemia unawareness)
• Acute oral issues impairing chewing or swallowing
• Sedation
• Longer procedures
What signs should concern you?
• Anxiety
• Sweating
• Uncooperativeness
• Confusion
• Sedation
• Decreased pain response
What Should You Do?
• Immediately stop the procedure• If aware and cooperative, give something
to eat• If possible have the patient check their
glucose• For unresponsive patient:
– Call 911– Give glucagon if available– 50% dextrose intravenously– Do not put food in the mouth
Learning Objectives
• Appreciate the challenge of diabetes from the patient’s perspective
• Differentiate type 1 from type 2• Understand insulin action• Understand complications of diabetes• Recognize major classes of medications• Recognize side effects of each class• Recognize potential complications affecting
dental care
Diabetes Essentials 2011
Richard LeBlond, MD, MACPChief Quality Officer
Professor, Internal MedicineUniversity of Iowa Health Care
QUESTIONS?
Complications of Diabetes: Ketoacidosis
• Insufficient insulin• Glucose cannot enter muscle so glucose levels
rise• Absent insulin signal to liver and fat• Fat releases triglycerides which are metabolized
in muscle to ketoacids• Liver starts making glucose further increasing
glucose• Osmotic diuresis leads to volume depletion• Ketoacids produces metabolic acidosis
aggravated by volume depletion• Death from severe acidosis and hypotension
Treatment of Ketoacidosis
1. Replace volume deficits with normal saline, usually several liters
2. Intravenous insulin drip
3. Replace electrolytes, particularly KCl
4. Continue insulin drip even when glucose becomes normal
5. Transition to subcutaneous insulin after all metabolic abnormalities are corrected
Care at Home Locus of Care
Personal Organism Social Person
Shared Responsibility: Who is responsible and accountable for what
• Ask the patient “whose problem is this?”
– Repeat and wait until the patient (not the spouse, family member, etc.) acknowledges their responsibility
– The outcome is most dependent upon the patient’s not the doctor’s activities
– The patient will receive the benefits or consequences of the decisions and actions
What should we conclude?
• Benefit is achieved in reducing A1c from > 9.0 to <7.0%
• No clear benefit with lowering A1c to ≤ 6.5%• A1c is a continuous not dichotomous variable
– One studies “intensive” is the next study’s control• Recent studies show increased harm, including
death, with more intensive therapy • Severe hypoglycemia increased with intensive
therapy• Achieving tight control is resource intensive
(time, drugs, supplies, emotional)
In the absence of clearly-defined goals we become strangely loyal to performing daily trivia until ultimately we become enslaved by it.
-Robert Heinlein
Symptoms of Diabetes
• Weight Loss
• Increased Appetite
• Increased Urination– Large urine volumes– Frequent voiding at night
• Visual Changes: blurring
• Fatigue, decreased energy
Diabetes Management
• The patient not the doctor manages diabetes• Doctor, docere L. teacher• Diet: count carbohydrates and total calories• Exercise: regular aerobic exercise 30+ minutes >
3 days per week• Home glucose monitoring: a learning tool• Glucose lowering medications• Manage other risk factors: BP, cholesterol,
tobacco use
The main problem with communication is the assumption that it has occurred.
-George Bernard Shaw