糖尿病英文ppt课件

2020 2 24 BeijingXuanwuHospital 1 DiabetesMellitus 2020 2 24 BeijingXuanwuHospital 2 DiabetesMellitus definitiontypessymptomsdiagnosisLaboratoryfindingstreatmentcomplications 2020 2 24 BeijingXuanwuHospital 3 Definition WHO 4 2000 Thetermdiabetesmellitusdescribesametabolicdisorderofmultipleaetiologycharacterizedbychronichyperglycaemiawithdisturbancesofcarbohydrate fatandproteinmetabolismresultingfromdefectsininsulinsecretion insulinaction orboth 2020 2 24 BeijingXuanwuHospital 4 Definition AmetabolicconditioncharacterisedbyhighplasmaglucoselevelsandchronicvascularcomplicationsAvasculardiseaseaffectingsmallandlargearterieswithcoexistentmetabolicdisturbanceparticularlyhighplasmaglucoselevels 2020 2 24 BeijingXuanwuHospital 5 DiabetesMellitus definitiontypessymptomsdiagnosisLaboratoryfindingstreatmentcomplications 2020 2 24 BeijingXuanwuHospital 6 AetiologicalClassificationofDisordersofGlycaemia Type1 beta celldestruction usuallyleadingtoabsoluteinsulindeficiency Autoimmune IdiopathicType2 mayrangefrompredominantlyinsulinresistancewithrelativeinsulindeficiencytoapredominantlysecretorydefectwithorwithoutinsulinresistance OtherspecifictypesGeneticdefectsofbeta cellfunctionGeneticdefectsininsulinactionDiseasesoftheexocrinepancreasEndocrinopathiesDrug orchemical inducedInfectionsUncommonformsofimmune mediateddiabetesOthergeneticsyndromessometimesassociatedwithdiabetesGestationaldiabetes 2020 2 24 BeijingXuanwuHospital 7 Type1diabetes PreviouslyknownasIDDM Insulindependentdiabetes Ketosisprone Usuallydiagnosedinyoungeragegroup 30years Peakincidence11 13yr Prevalencehighlyvariablebutapproximately0 20 withanincidenceof15 20per100000populationagedlessthan21Seasonalvariation withlowestrateinspringandsummer 2020 2 24 BeijingXuanwuHospital 8 Type1diabetesmellitus Immune mediatedtype1diabetesacuteLADAlatentautoimmunediabetesinadultsIdiopathictype1diabetesmellitus 2020 2 24 BeijingXuanwuHospital 9 Type1diabetesmellitus GeneticsEnvironmentalfactorVirusesChemicalagentsAutoimmuneAuto antibodies isletcellcytoplasmantibody ICCA isletcellsurfaceantibody ICSA glutamicaciddecarboxylaseantibodyGADA 64KD Insulinantibody IAA 2020 2 24 BeijingXuanwuHospital 10 Type1diabetes ThispresentationistheendpointofrecentandcontinuingbetacellfunctionresultinginneartotallossofInsulinproductionHyperglycaemiaitselfbegetsfurtherbetacelldestructionastreatmentwithinsulinoftenresultsina honeymoon periodwhenthepatientcanoftenmanagewithoutinsulin 2020 2 24 BeijingXuanwuHospital 11 Type1diabetesmellitususuallyautoimmunedestructionofinsulin producingpancreaticislet cellsovermonthsabsoluteinsulindeficiencyrapidpresentationwiththirst polyuria weightloss blurredvisionthrush lethargy dizziness nausea vomiting abdominalcramps andsuperficialinfectionusuallythinandketoticatpresentationAuto antibodiesidentified antiisletcell ICCA ICSA antiGAD 64KD antiInsulin IAA 2020 2 24 BeijingXuanwuHospital 12 Aprogressivemetabolicdisordercharacterisedby Insulinresistance Type2diabetes celldysfunction 2020 2 24 BeijingXuanwuHospital 13 Type2diabetes PreviouslyknownasNIDDMNonketosisprone diagnosis 30years1in1000populationasnewcaseseachyearInsidiouspresentationwithsymptomsofpolyuria polydipsia lethargy weightloss nausea vomiting abdominalcramps blurredvisionandsuperficialinfection OftendiscoveredatroutinemedicalThispresentationistheendpointofthegraduallossofbetacellfunctioninthesettingofInsulinresistanceStrong 90 100 concordanceinTwinsReavan ssyndromeorSyndromeXInsulinresistance 2020 2 24 BeijingXuanwuHospital 14 Type2diabetesUnderlyinginsulinresistancegeneticandethnicityObesityBMIWHRinactivity lowphysicalfitnessintrauterine childhoodfactorssmoking drugsImpairedinsulinsecretionInsulinsecretionworsenswithtime 2020 2 24 BeijingXuanwuHospital 15 Type2diabetes 2020 2 24 BeijingXuanwuHospital 16 Pancreatic cell Insulinresistance Liver HYPERGLYCAEMIA Islet celldegranulationReducedinsulincontent Adiposetissue Decreasedglucosetransport activity expression ofGLUT 4 Increasedlipolysis ElevatedplasmaNEFA Lowplasmainsulin Increasedglucoseoutput ElevatedTNF Insulinresistanceand celldysfunctionproducehyperglycaemiaintype2diabetes 2020 2 24 BeijingXuanwuHospital 17 TissueResponsestoInsulinResistanceorFailure LIVERa increasedglycogenhydrolysistoglucoseb increasedgluconeogenesis c increasedtriacylglycerolhydrolysisandconversionofglyceroltoglucosed increasedconversionofFAandproteintoketones AcAcandBHB e increasedproteinandaminoacidcatabolismf increasedproductionofurea 2020 2 24 BeijingXuanwuHospital 18 MUSCLE a serumglucoseispoorlytakenupbymuscle decreaseGLUTactivity b saturationofhexokinaseactivity inabilitytoretaincellulargluasglu 6 PO4c increasedLPLactivityandincreasedFAproductiond increasedb oxidation butTCAisoverwhelmedbecauseATPishighalreadyee increasedbreakdownofmuscleandserumproteinintoaminoacidsf increasedtransferofNontoALA GLNandsentbacktoliver 2020 2 24 BeijingXuanwuHospital 19 ADIPOSE a increasedLPLandHSLsendmorefreeFAintobloodstreamb glucosecannotbetakenintocellviaGLUT4forglycogensynthesisc activeHSLmeansTAGsarenotbeingmadeandstored 2020 2 24 BeijingXuanwuHospital 20 Insulinresistanceandinsulinhypersecretionprecedetype2diabetes InsulinInsulinMacrovascularsensitivitysecretiondisease30 50 50 50 70 100 40 70 150 10 100 100 Type2diabetes IGT Impairedglucosemetabolism Normalglucosemetabolism 2020 2 24 BeijingXuanwuHospital 21 ClinicalReavansSyndrome InsulinresistanceHypertensionDyslipidaemia increaseLDL decreasedHDL ObesityOtherfactors hyperfibrinogenemia hyperuricaemia propensitytomicrovasculardiseases Metabolicsyndrome inmostcasesoftype2diabetes 2020 2 24 BeijingXuanwuHospital 22 abdominalobesity highbloodpressure HDLcholesterol VLDLtriglyceride smalldenseLDL hyperinsulinaemiaglucoseintolerancediabetes hyperuricaemia PAI 1 fibrinogen factorVII microalbuminuria insulinresistance Syndromeofinsulinresistance AKAReaven ssyndrome syndromeXmetabolicsyndrome 2020 2 24 BeijingXuanwuHospital 23 Type1diabetestypicalonset 30yearscanstartatanyagesuddenonsetseveresymptomsrecentweightlossusuallythinspontaneousketosisabsentC peptidemarkersofautoimmunity Type2diabetestypicalonset 20yearscanstartatanyagegradualonsetmaybenosymptomsoftennoweightlossusuallyobesenotketoticdetectableC peptidenoautoimmunemarkers 2020 2 24 BeijingXuanwuHospital 24 Diabetesinpregnancyco existentornewlydiagnosedlifelongdiabetestype1type2 especiallyinSouthAsianwomen otherspecifictypesofdiabetesgestationaldiabetes 2020 2 24 BeijingXuanwuHospital 25 OthertypesofDiabetes Geneticdefectsofbeta cellfunctionChr me20 HNF4 MODY1 Chr me7 glucokinase MODY2 Chr me12 HNF1 MODY3 Chr me13 IPF 1 MODY4 MitochondrialDNA3243mutationGeneticdefectsininsulinactionTypeAinsulinresistanceLeprechaunismRabson MendenhallsyndromeLipoatrophicdiabetes Others Diseasesoftheexocrine pancreasFibrocalculouspancreatopathyPancreatitisTrauma pancreatectomyNeoplasiaCysticfibrosisHaemochromatosis OthersEndocrinopathiesCushing ssyndromeAcromegalyPhaeochromocytomaGlucagonomaHyperthyroidismSomatostatinoma Others 2020 2 24 BeijingXuanwuHospital 26 Types continued InfectionsCongenitalrubellaCytomegalovirusOthersUncommonformsofimmune mediateddiabetesInsulinautoimmunesyndrome antibodiestoinsulin Anti insulinreceptorantibodies StiffMan syndromeOthers Drug orChemical inducedDiabetesNicotinicacidGlucocorticoidsThyroidhormoneAlpha adrenergicagonistsBeta adrenergicagonistsThiazidesDilantinPentamidineVacorInterferon alphatherapyOthers 2020 2 24 BeijingXuanwuHospital 27 Pathophysiology Becauseglucoseisnotgettingintocells metabolismchangesCatabolismoffatsandproteinsinsteadofcarbohydratesLeadstoincreasedfattyacidsandketoacidsKetoacidosisresultsinloweringofpHDiabeticcomaDecompensatedmetabolicacidosisanddeath 2020 2 24 BeijingXuanwuHospital 28 DiabetesMellitus definitiontypessymptomsdiagnosisLaboratoryfindingstreatmentcomplications 2020 2 24 BeijingXuanwuHospital 29 Symptomsofdiabetesduetohyperglycaemia HyperglycemiaDehydrationExcessivethirstandurinationExcessivehungerGlycosuria gluspillsintourine 180mg dl 2020 2 24 BeijingXuanwuHospital 30 Symptomsofdiabetesduetohyperglycaemia plasmaglucose renalthresholdabout12mmol L glucoseinurineosmoticdiuresis hyperglycaemia tiredness 2020 2 24 BeijingXuanwuHospital 31 Symptomsofdiabetesduetohyperglycaemia hyperglycaemia swellingoflensblurredvisioncerebraleffectslightheadednessmalaisementalchanges 2020 2 24 BeijingXuanwuHospital 32 DiabetesMellitus definitiontypessymptomsdiagnosisLaboratoryfindingstreatmentcomplications 2020 2 24 BeijingXuanwuHospital 33 ADAdiagnosticcriteria 1997 SymptomsofdiabetesCasualisdefinedasanytimeofdaywithoutregardstotimesincelastmeal Theclassicsymptomsofdiabetesincludepolyuria polydipsiaandunexplainedweightlossorFPGmorethanorequalto126mg dl 7 0mmol l Fastingisdefinedasnocaloricintakeforatleast8hoursor2hourPGmorethanorequalto200mg dl 11 1mmol l duringanOGTT ThetestshouldbeperformedasdescribedbyWHO usingaglucoseloadcontainingtheequivalentof75gglucosedissolvedinwater 2020 2 24 BeijingXuanwuHospital 34 WHOdiagnosticcriteria wholebloodplasmaDiabetesmellitus fasting 6 1mmol l 7 0mmol l2hourpostglucoseload 10 0mmol l 11 1mmol lIGT fasting 6 7mmol l 7 8mmol lIFG fasting 5 6mmol l 6 1mmol l 6 7mmol l 7 8mmol lIGHimpairedglucosehomeostasis 2020 2 24 BeijingXuanwuHospital 35 ChangesfromOldcriteria Theclass ImpairedGlucoseTolerance isnowclassifiedasastageofimpairedglucoseregulation sinceitcanbeobservedinanyhyperglycaemicdisorder andisitselfnotdiabetes ClinicalstageofImpairedFastingGlycaemiahasbeenintroducedtoclassifyindividualswhohavefastingglucosevaluesabovethenormalrange butbelowthosediagnosticofdiabetes GestationalDiabetesisretainedbutnowencompassesthegroupsformerlyclassifiedasGestationalImpairedGlucoseTolerance GIGT andGestationalDiabetesMellitus GDM 2020 2 24 BeijingXuanwuHospital 36 Diagnosisofdiabetessymptoms elevatedbloodglucoselevelORelevatedbloodglucoselevelsontwooccasions 2020 2 24 BeijingXuanwuHospital 37 DifferentialDiagnosis HyperglycemiasecondarytoothercausesNondiabeticglycosuria 2020 2 24 BeijingXuanwuHospital 38 DiabetesMellitus definitiontypessymptomsdiagnosisLaboratoryfindingstreatmentcomplications 2020 2 24 BeijingXuanwuHospital 39 FPG FastingPlasmaGlucoseCPG CasualPlasmaGlucose non fasting OGTT OralGlucoseToleranceTest 75g HemoglobinA1c glycatedhemoglobin glycosylatedhemoglobin IndicatesaverageBGlevelsoverapprox 3months oftotalHgbattachedtoglucoseNormal 4 6 DM 8 2020 2 24 BeijingXuanwuHospital 40 Laboratoryfindings Glucose FBG 2hrOGTT FBGissimple accurate convenientforpatientGlycohemoglobinCreatinineUrinalysisglucoseketonebodiesMicroalbuminDyslipidemiaInsulinc peptide 2020 2 24 BeijingXuanwuHospital 41 DiabetesMellitus definitiontypessymptomsdiagnosisLaboratoryfindingstreatmentcomplications 2020 2 24 BeijingXuanwuHospital 42 TreatmentofDiabetes NonPharmacologicalExerciseandEducationDiet Lowinfat lowrefinedsugars highcarbohydrate highfibre lowcaloriesifobese spacingofmeals Healthyeating LowcholesterolandtriglyceridedietifhyperlipidemiaAllType1patientswillrequireInsulinandtype2canbeondietonly tabletsorinsulintreated 2020 2 24 BeijingXuanwuHospital 43 Treatmentofdiabetes type1type2GDM diet exercise insulindiet exercisemetforminorsulphonylureaalonemetforminandsulphonylureametformin sulphonylurea thiazolidinedioneinsulindietinsulin 2020 2 24 BeijingXuanwuHospital 44 DrugstotreathyperglycaemiaInsulinandinsulinanaloguesInsulinsecretagoguessulphonylureanon sulphonylureaInsulinsensitizersbiguanidethiazolidinedioneIntestinalabsorptioninhibitorsacarboseorlistat gliclazide glibenclamide repaglinide nateglinide metformin rosiglitazone pioglitazone 2020 2 24 BeijingXuanwuHospital 45 sulphonylureaagentsgliclazide glibenclamide glimepiridebindtoreceptorson isletcellsincreaseinsulinsecretionfrom isletcellslongdurationofaction12 48hoursAdverseffectincreaseweightcancausehypoglycaemiacancauserashesContraindicationssulfaallergytype1DM DKA 2020 2 24 BeijingXuanwuHospital 46 Meglitinides Mechanism Bindstositeonbeta cellmembraneleadingtoinsulinreleaseRapidoralabsorptionandeliminationforuseincontrollingpost prandialhyperglycemia Examples repaglinide nateglinideContraindicationsType1DM DKAAdverseeffects Hypoglycemia weightgain 2020 2 24 BeijingXuanwuHospital 47 metforminlowersliverglucoseoutputincreasestissueglucoseuptakeactslikeaninsulinsensitizermildinductionofnauseapossibleinterferencewithfoodabsorptionnoeffectonweightusedalonedoesnotcausehypoglycaemiareducesriskofmyocardialinfarction1 3patientsgetdiarrhoea windorabdominalpainnotusedinrenalfailure heartfailureorsevereintercurrentillness 2020 2 24 BeijingXuanwuHospital 48 MetforminToxicity Renallyexcreted notmetabolizedPotentiallyfatallacticacidosisContraindications renalinsufficiency decreasesdrugclearance hepaticdysfunction decreaseslactatemetabolism tissueanoxia increaselactateproduction 2020 2 24 BeijingXuanwuHospital 49 acarbose glucosidaseinhibitorblocksdigestionandabsorptionofsugarsfrombowellowersbloodglucoseandinsulinlevelsaftermealsweakantidiabeticdrugnoeffectonweightusedalonedoesnotcausehypoglycaemianotabsorbedintobody1 2patientsgetdiarrhoea windorabdominalpain 2020 2 24 BeijingXuanwuHospital 50 a glucosidaseinhibitortoxicity UnabsorbedCHO s Bacterialfermentationincolonresultsinabdominalpain flatulencefromgasOsmoticdiarrheaElevatedserumtransaminasesMetabolizedandexcretedintheGItractSomemetaboliteisabsorbedinGIandrenallyexcretedContraindicatedforpatient swithchronicorinflammatoryboweldiseaseRelativelyweakantidiabeticeffect usuallyusedadjunctively 2020 2 24 BeijingXuanwuHospital 51 thiazolidinedioneagentsrosiglitazone pioglitazone Mechanism BindtoPPAR gammareceptorinperipheraltissuesmainlyskeletalmuscleResultinexpressionofcell surfaceglucosetransporters CautionsNotrecommendedinNYHAClassIII IVCHFMaycausefluidretentionandprecipitateCHFMaycausemildanemia Dilutionaleffect 2020 2 24 BeijingXuanwuHospital 52 thiazolidinedioneagents AssociatedwithweightgainLivertoxicityseeninolderTZD troglitazone butnotwithneweragents recommendedtocheckLFTsq2mofor1styearofuse AdvantagesNohypoglycemiaPossibleimprovementinvascularfunction 2020 2 24 BeijingXuanwuHospital 53 Thiazolidinedionetoxicity Metabolism hepaticconjugationbytheCYP450systemExcretion biliaryHepatotoxic especiallytroglitazone andcontraindicatedincasesofhepaticdysfunctionCancauseedemaandhypoglycemiawhenusedincombinationwithotherhypoglycemics 2020 2 24 BeijingXuanwuHospital 54 Treatinghyperglycaemiaintype2diabetes dietarychangeexercise metformin sulphonylurea glitazone metforminORglitazone sulphonylurea insulin metformin Aim HbA1c 6 5 Fastingglucose 7mmol l 2020 2 24 BeijingXuanwuHospital 55 insulinanditsanaloguestheonlytreatmentfortype1diabetesalsousedfortype2diabetesandGDMcancausehypoglycaemiacausesweightgaincancausefluidretention 2020 2 24 BeijingXuanwuHospital 56 Threemainprofiles humanbio engineered porkorBovine Variousregimens twicedailysolubleandisophane thricedailysoluble pre meal andeveningisophane rarelyoncedaily 2020 2 24 BeijingXuanwuHospital 57 2020 2 24 BeijingXuanwuHospital 58 Basalbolus Intermediate Normal Long 30 70mix 2020 2 24 BeijingXuanwuHospital 59 RecommendedTreatment 1stline Dietandexercise2ndlineoralhypoglycemicmonotherapy glyburide adjunctiveto1stlinetreatmentSecond third andevenafourthclassofhypoglycemicscanactsynergisticallyformorediresituationsWhenallelsefails backtotheneedle insulintherapy 2020 2 24 BeijingXuanwuHospital 60 EarlyAMHyperglycemia PossibleCauses DawnphenomenonRiseinBGinearlymorningastheresultofpulsatilereleaseofinsulincounter regulatoryhormones growthhormoneandcortisol SomogyiphenomenonPeriodofmorninghyperglycemiafollowingnocturnalhypoglycemia Studieshavefailedtoshowthatthisoccurscommonly NPHinsulingivenatdinnerwithwaningeffectbyAMLatenightsnacking 2020 2 24 BeijingXuanwuHospital 61 DiabetesMellitus definitiontypesPrevalencesymptomsdiagnosistreatmentcomplications 2020 2 24 BeijingXuanwuHospital 62 DiabeticComplications AcuteComplication hypoglycaemia ketoacidosisoftenwithcoma DKA Hyperosmolarstateoftenwithcoma HONK MicrovascularcomplicationsDiabeticretinopathy nephropathyandneuropathyMacrovascularcomplicationcerebrovascularaccidents coronaryarterydisease hypertension peripheralvasculardiseasePregnancywithincreasedmaternalandfoetalmorbidity 2020 2 24 BeijingXuanwuHospital 63 Vascularcomplicationsofdiabetes retinopathynephropathyneuropathycoronaryarterydiseasecerebrovasculardiseaseperipheralvasculardisease 2020 2 24 BeijingXuanwuHospital 64 Diabeticretinopathyleadingcauseofblindness95 ofdiabeticsubjectsshowsomeby15yearsafteronsetriskfactors agediabetesdurationhighbloodglucoselevelshighbloodpressuregeneticsmayprogressrapidlyduringpregnancy 2020 2 24 BeijingXuanwuHospital 65 Diabeticretinopathy Cataractformation glycation crystallin RetinopathyNonproliferative microaneurysms edemaProliferative VEGF Newbloodvesselsthatextendintovitreous bleeding lossofvisionGlaucoma intraocularpressure oculartissuedamage 2020 2 24 BeijingXuanwuHospital 66 Non proliferativediabeticretinopathy NPDR EarlieststageMicroaneurismsandintraretinal dotandblot hemorrhagesMacularedemaorhardexudatesat nearmaculacancausevisualimpairmentProliferativediabeticretinopathy PDR Nonperfusionofretina angiogenesis growthofabnormalnewvesselsextendingontoinnersurfaceofretinaorintovitreouscavity Substantialriskforrupture hemorrhageorretinaldetachment Treatedwithpanretinalphotcoagulation 2020 2 24 BeijingXuanwuHospital 67 DiabeticnephropathyAffects25 oftype1andtype2diabetespatientsRiskfactorssimilartothoseforretinopathyIsaprogressiveconditionleadingtorenalfailureCharacterisedbyproteinuriaandhighbloodpressure 2020 2 24 BeijingXuanwuHospital 68 Diabeticnephropathy Glomerulosclerosis Capillarybasementmembr thickening Microalbuminuria 30 300mg 24hr Hyperfiltration GFR Albuminuria 300mg 24hr HypertensionNephroticsyndrome approx1 3ofType1progresstoendstagerenaldisrequiringdialysis Renalfailure GFR Creat 2020 2 24 BeijingXuanwuHospital 69 Diabeticneuropathy TypesofNeuropathySensoryPain paresthesiasinfeetparticularlyatnightNumbnessin stockingandglove distributionHighriskforfootulcerationAutonomic