28/06/35 Salman Bin AbdulAziz University College Of Pharmacy Diabetes Mellitus Cases Therapeutics I PHCL 416 Professor Muhammad Abdulmotaal Ahmed A AlAmer PharmD Email :[email protected]  R.P. is a 43-year-old African American woman visiting the drop-in clinic to obtain a routine physical examination for her new job. Her past medical history is signiﬁcant for GDM. She was told during her two pregnancies (last child born 3 years ago) that she had “borderline diabetes,” which resolved each time after giving birth.  Her family history is signiﬁcant for type 2 diabetes (mother, maternal grandmother, older ﬁrst cousin), hypertension, and CVD. She denies tobacco or alcohol use. She states she tries to walk 15 minutes twice a week. 1 28/06/35 Physical examination is signiﬁcant for moderate central obesity (5 feet 4 inches; 160 lbs; BMI, 30.2 kg/m2) and BP 145/85 mmHg. R.P. denies any symptoms of polyphagia, polyuria, or lethargy. Upon checking her electronic medical record, she has documented hypertension and an FPG value of 119 mg/dL, measured 2 months prior. What features of R.P.’s history and examination are consistent with an increased risk of developing type 2 diabetes? 2 28/06/35 increased risk of developing type 2 diabetes? 1- age 2- ethnicity 3- weight 4- family history of diabetes 5- history of GDM 6- documented IFG. 7- hypertension. 2. The physician orders another FPG for R.P., which comes back at 122 mg/dL. How should R.P. be managed at this time? A. Patient education ..………………………………………………………….... diabetes. About risk factors of developing B. lifestyle modiﬁcations (MNT, physical activity)………. for lose weight, improve her cardiovascular health decrease her risk for developing type 2 diabetes. Medical Nutrition Therapy= MNT 3 28/06/35 Treatment There are three major components to the treatment of diabetes: 1- diet 2- drugs (insulin and oral hypoglycemic agents, and other antihyperglycemic agents) 3- exercise. Q What are the three major components to the treatment diabetes? Q how to manage patient with increased risk of developing D.M? Q life style modification benefits ? 4 28/06/35 A.H., a slender, 18-year-old woman who was recently discharged from the hospital for severe dehydration and mild ketoacidosis is referred to the Diabetes Clinic (no records available). A fasting and a random plasma glucose ordered subsequently were 190 mg/dL (normal, 70–100) and 250mg/dL (normal, 140 to<200). 4weeks before she was hospitalized, A.H. she remembers that she had symptoms of polydipsia, nocturia (six times a night), fatigue, and a 12-lb weight loss over this period, which she attributed to the anxiety associated with her move away from home and adjustment to her new environment.  Medical history I. recurrent upper respiratory infections II. three cases of vaginal moniliasis over the past 6 months.  Family history is negative for diabetes, and she takes no medications.  Physical examination is within normal limits. (weight 50 kg and is 5 feet 4 inches tall)  Laboratory results are as follows: FPG, 280 mg/dL (normal, <100); HbA1c, 14%(normal, 4%–6%); and trace urine ketones as measured by Keto-Diastix (normal, negative). 5 28/06/35  A,H diagnosis is consistent with ? A. B. C. D. D.M type I D.M type 2 Impaired fasting blood glucose (IFG) Non of the above Define Diabetes ? Compare between type I DM and Type 2 DM ? Diagnosis of DM? 6 28/06/35 Subjective , Objective , assessment for this case ? 1- She has classic symptoms of the disease (polyuria, polydipsia, weight loss, glucosuria, fatigue, recurrent infections) 2-A random plasma glucose above 200 mg/dL 3- FPG of 126 mg/dL or higher on at least two occasions4 6- ketones in the urine, 4- elevated HbA1c 5- Features of A.H.’s history that are consistent with type 1 diabetes, in particular, include the relatively acute onset of symptoms in association with a major life event (moving away from home), 7- negative family history 8- a relatively young age at onset 9- vaginal infection.and URTI WHY? This patient has ……………. D.M type I 7 28/06/35 A.H. will be started on insulin therapy on this visit. What are the goals of therapy? A. Prevent the onset of Acute complications Chronic complications Hypoglycemia, diabetic ketoacidosis (DKA) Hyperglycemic hyperosmolar nonketotic syndrome Microvascular: Retinopathy, nephropathy, and neuropathy Macrovascular: Cardiovascular, cerebrovascular, and peripheral vascular diseases A.H. will be started on insulin therapy on this visit. What are the goals of therapy for D.M? B. Glycemic therapy goals I. HgA1c less than 7.0%. (Note: The ACE/AACE guidelines recommend 6.5% or less for selected patient those with short duration of diabetes, long life expectancy, and no significant CVD.) II. Less stringent A1C goals (such as < 8%) 1. Patient with of severe hypoglycemia, 2. limited life expectancy, advanced microvascular macrovascular complications, 3. extensive comorbid conditions 8 28/06/35 A.H. will be started on insulin therapy on this visit. What are the goals of therapy for D.M? B. Glycemic therapy goals III. FPG 70–130 mg/dL. Frequency of monitoring very dependent on regimen, type of DM) IV . Peak postprandial glucose (1–2 hours after a meal) less than 180 mg/dL C. Non-glycemic therapy goals BP goal of < 140/ 80 mHg. ( Updated 2013 in ADA guidelines ) BP goal < 130/80 mmHg in young patient with no burden LDL cholesterol < 100 mg/dL HDL cholesterol >50 mg/dL, Triglycerides <150 mg/dL), Mention chronic complication of D.M ? Mention acute complications of D.M ? What are the glycemic control target ? HgA1c goals in patient with diabetes ? Blood pressure goals in patient with D.M ? Lipid profile targets for patient with D.M ? 9 28/06/35 Type 2 DM Case A 66-year-old man is given a diagnosis of type 2 DM today. His A1c was 8.2%, and his serum creatinine was 1.8 mg/dL 2 weeks ago. He has a history of hypertension, dyslipidemia, and systolic heart failure (New York Heart Association class III, ejection fraction 33%). He has 2+ pitting edema bilaterally. In addition to improvements in diet and exercise SOAP this case S O A P. 10 28/06/35 A 33-year-old white man is brought to the emergency department by ambulance after being found minimally responsive with Kussmaul-type respirations and hyperglycemia. He is transferred to the intensive care unit with chief concerns of abdominal pain, nausea/vomiting, and thirst. PMH: Type 1 diabetes Allergies: NKDA Current Medications: Insulin glargine 20 units subcutaneously daily Insulin lispro 10 units subcutaneously with meals Vital signs: BP 88/48 mm Hg, HR 125 beats/minute, RR 15 breaths/minute Laboratory values: Glucose 593 mg/dL, serum sodium 136 mmol/L, serum ketones positive, urine ketones positive The patient is given a diagnosis of diabetic ketoacidosis (DKA). 1. More common in type 1 DM but can occur in type 2 DM 2. Usually occurs because of a precipitating factor that considerably stresses the body, resulting in increased counterregulatory hormones a. Inappropriate (including nonadherence) or inadequate insulin therapy and infection are the two most common causes. b. Other causes: Myocardial infarction, pancreatitis, stroke, drugs (e.g., corticosteroids) 11 28/06/35 What are common signs and symptoms of DKA? Common signs/symptoms: Polyuria, polydipsia, vomiting, dehydration, weakness, altered mental status, coma, abdominal pain, Kussmaul respirations, tachycardia, hyponatremia, hyperkalemia What are differences in diagnostic criteria and severity classification for DKA and hyperosmolar hyperglycemic state (HHS)? 12 28/06/35 Sources I. Koda Kimble , applied therapeutics II. Pharmacotherapy Bedside Guide Christopher P. Martin, Robert L. Talbert III. Updates in Therapeutics: The Pharmacotherapy Preparatory Review IV. Executive Summary: Standards of Medical Care in Diabetes 2013 http://care.diabetesjournals.org/content/36/Supplement_1/S4.f ull.pdf+html 13