糖尿病基础知识英文.ppt

DiabetesMellitus Dr RashaSalamaPhDPublicHealth SuezCanalUniversity EgyptDiabetesMSc CardiffUniversity UnitedKingdom Diabetesmellitus DM isagroupofdiseasescharacterizedbyhighlevelsofbloodglucoseresultingfromdefectsininsulinproduction insulinaction orboth Thetermdiabetesmellitusdescribesametabolicdisorderofmultipleaetiologycharacterizedbychronichyperglycaemiawithdisturbancesofcarbohydrate fatandproteinmetabolismresultingfromdefectsininsulinsecretion insulinaction orboth Theeffectsofdiabetesmellitusincludelong termdamage dysfunctionandfailureofvariousorgans Whatisdiabetes Diabetesmellitusmaypresentwithcharacteristicsymptomssuchasthirst polyuria blurringofvision andweightloss Initsmostsevereforms ketoacidosisoranon ketotichyperosmolarstatemaydevelopandleadtostupor comaand inabsenceofeffectivetreatment death Oftensymptomsarenotsevere ormaybeabsent andconsequentlyhyperglycaemiasufficienttocausepathologicalandfunctionalchangesmaybepresentforalongtimebeforethediagnosisismade Diabetes Thelong termeffectsofdiabetesmellitusincludeprogressivedevelopmentofthespecificcomplicationsofretinopathywithpotentialblindness nephropathythatmayleadtorenalfailure and orneuropathywithriskoffootulcers amputation Charcotjoints andfeaturesofautonomicdysfunction includingsexualdysfunction Peoplewithdiabetesareatincreasedriskofcardiovascular peripheralvascularandcerebrovasculardisease DiabetesLong termEffects Thedevelopmentofdiabetesisprojectedtoreachpandemicproportionsoverthenext10 20years InternationalDiabetesFederation IDF dataindicatethatbytheyear2025 thenumberofpeopleaffectedwillreach333million 90 ofthesepeoplewillhaveType2diabetes InmostWesternsocieties theoverallprevalencehasreached4 6 andisashighas10 12 among60 70 year oldpeople Theannualhealthcostscausedbydiabetesanditscomplicationsaccountforaround6 12 ofallhealth careexpenditure BurdenofDiabetes Type1DiabetesMellitusType2DiabetesMellitusGestationalDiabetesOthertypes LADA MODY maturity onsetdiabetesofyouth SecondaryDiabetesMellitus TypesofDiabetes Waspreviouslycalledinsulin dependentdiabetesmellitus IDDM orjuvenile onsetdiabetes Type1diabetesdevelopswhenthebody simmunesystemdestroyspancreaticbetacells theonlycellsinthebodythatmakethehormoneinsulinthatregulatesbloodglucose Thisformofdiabetesusuallystrikeschildrenandyoungadults althoughdiseaseonsetcanoccuratanyage Type1diabetesmayaccountfor5 to10 ofalldiagnosedcasesofdiabetes Riskfactorsfortype1diabetesmayincludeautoimmune genetic andenvironmentalfactors Type1diabetes Waspreviouslycallednon insulin dependentdiabetesmellitus NIDDM oradult onsetdiabetes Type2diabetesmayaccountforabout90 to95 ofalldiagnosedcasesofdiabetes Itusuallybeginsasinsulinresistance adisorderinwhichthecellsdonotuseinsulinproperly Astheneedforinsulinrises thepancreasgraduallylosesitsabilitytoproduceinsulin Type2diabetesisassociatedwitholderage obesity familyhistoryofdiabetes historyofgestationaldiabetes impairedglucosemetabolism physicalinactivity andrace ethnicity AfricanAmericans Hispanic LatinoAmericans AmericanIndians andsomeAsianAmericansandNativeHawaiiansorOtherPacificIslandersareatparticularlyhighriskfortype2diabetes Type2diabetesisincreasinglybeingdiagnosedinchildrenandadolescents Type2diabetes Aformofglucoseintolerancethatisdiagnosedinsomewomenduringpregnancy GestationaldiabetesoccursmorefrequentlyamongAfricanAmericans Hispanic LatinoAmericans andAmericanIndians Itisalsomorecommonamongobesewomenandwomenwithafamilyhistoryofdiabetes Duringpregnancy gestationaldiabetesrequirestreatmenttonormalizematernalbloodglucoselevelstoavoidcomplicationsintheinfant Afterpregnancy 5 to10 ofwomenwithgestationaldiabetesarefoundtohavetype2diabetes Womenwhohavehadgestationaldiabeteshavea20 to50 chanceofdevelopingdiabetesinthenext5 10years Gestationaldiabetes Otherspecifictypesofdiabetesresultfromspecificgeneticconditions suchasmaturity onsetdiabetesofyouth surgery drugs malnutrition infections andotherillnesses Suchtypesofdiabetesmayaccountfor1 to5 ofalldiagnosedcasesofdiabetes OthertypesofDM LatentAutoimmuneDiabetesinAdults LADA isaformofautoimmune type1diabetes whichisdiagnosedinindividualswhoareolderthantheusualageofonsetoftype1diabetes Alternatetermsthathavebeenusedfor LADA includeLate onsetAutoimmuneDiabetesofAdulthood SlowOnsetType1 diabetes andsometimesalso Type1 5Often patientswithLADAaremistakenlythoughttohavetype2diabetes basedontheirageatthetimeofdiagnosis LADA LADA cont About80 ofadultsapparentlywithrecentlydiagnosedType2diabetesbutwithGADauto antibodies i e LADA progresstoinsulinrequirementwithin6years Thepotentialvalueofidentifyingthisgroupathighriskofprogressiontoinsulindependenceincludes theavoidanceofusingmetformintreatmenttheearlyintroductionofinsulintherapy LADA cont MODY MaturityOnsetDiabetesoftheYoungMODYisamonogenicformofdiabeteswithanautosomaldominantmodeofinheritance Mutationsinanyoneofseveraltranscriptionfactorsorintheenzymeglucokinaseleadtoinsufficientinsulinreleasefrompancreatic cells causingMODY DifferentsubtypesofMODYareidentifiedbasedonthemutatedgene Originally diagnosisofMODYwasbasedonpresenceofnon ketotichyperglycemiainadolescentsoryoungadultsinconjunctionwithafamilyhistoryofdiabetes However genetictestinghasshownthatMODYcanoccuratanyageandthatafamilyhistoryofdiabetesisnotalwaysobvious MODY MODY cont WithinMODY thedifferentsubtypescanessentiallybedividedinto2distinctgroups glucokinaseMODYandtranscriptionfactorMODY distinguishedbycharacteristicphenotypicfeaturesandpatternonoralglucosetolerancetesting GlucokinaseMODYrequiresnotreatment whiletranscriptionfactorMODY i e Hepatocytenuclearfactor 1alpha requireslow dosesulfonylureatherapyandPNDM causedbyKir6 2mutation requireshigh dosesulfonylureatherapy MODY cont SecondarycausesofDiabetesmellitusinclude Acromegaly Cushingsyndrome Thyrotoxicosis PheochromocytomaChronicpancreatitis CancerDruginducedhyperglycemia AtypicalAntipsychotics Alterreceptorbindingcharacteristics leadingtoincreasedinsulinresistance Beta blockers Inhibitinsulinsecretion CalciumChannelBlockers Inhibitssecretionofinsulinbyinterferingwithcytosoliccalciumrelease Corticosteroids Causeperipheralinsulinresistanceandgluconeogensis Fluoroquinolones InhibitsinsulinsecretionbyblockingATPsensitivepotassiumchannels Naicin Theycauseincreasedinsulinresistanceduetoincreasedfreefattyacidmobilization Phenothiazines Inhibitinsulinsecretion ProteaseInhibitors Inhibittheconversionofproinsulintoinsulin ThiazideDiuretics Inhibitinsulinsecretionduetohypokalemia Theyalsocauseincreasedinsulinresistanceduetoincreasedfreefattyacidmobilization SecondaryDM Prediabetesisatermusedtodistinguishpeoplewhoareatincreasedriskofdevelopingdiabetes Peoplewithprediabeteshaveimpairedfastingglucose IFG orimpairedglucosetolerance IGT SomepeoplemayhavebothIFGandIGT IFGisaconditioninwhichthefastingbloodsugarleveliselevated 100to125milligramsperdecilitreormg dL afteranovernightfastbutisnothighenoughtobeclassifiedasdiabetes IGTisaconditioninwhichthebloodsugarleveliselevated 140to199mg dLaftera2 houroralglucosetolerancetest butisnothighenoughtobeclassifiedasdiabetes Prediabetes Impairedglucosetoleranceandimpairedfastingglucose Progressiontodiabetesamongthosewithprediabetesisnotinevitable Studiessuggestthatweightlossandincreasedphysicalactivityamongpeoplewithprediabetespreventordelaydiabetesandmayreturnbloodglucoselevelstonormal Peoplewithprediabetesarealreadyatincreasedriskforotheradversehealthoutcomessuchasheartdiseaseandstroke Prediabetes Impairedglucosetoleranceandimpairedfastingglucose cont DiagnosisofDiabetesMellitus ValuesofDiagnosisofDiabetesMellitus Researchstudieshavefoundthatlifestylechangescanpreventordelaytheonsetoftype2diabetesamonghigh riskadults ThesestudiesincludedpeoplewithIGTandotherhigh riskcharacteristicsfordevelopingdiabetes Lifestyleinterventionsincludeddietandmoderate intensityphysicalactivity suchaswalkingfor21 2hourseachweek IntheDiabetesPreventionProgram alargepreventionstudyofpeopleathighriskfordiabetes thedevelopmentofdiabeteswasreduced58 over3years Preventionordelayofdiabetes Lifestylemodification Studieshaveshownthatmedicationshavebeensuccessfulinpreventingdiabetesinsomepopulationgroups IntheDiabetesPreventionProgram peopletreatedwiththedrugmetforminreducedtheirriskofdevelopingdiabetesby31 over3years Treatmentwithmetforminwasmosteffectiveamongyounger heavierpeople those25 40yearsofagewhowere50to80poundsoverweight andlesseffectiveamongolderpeopleandpeoplewhowerenotasoverweight Similarly intheSTOP NIDDMTrial treatmentofpeoplewithIGTwiththedrugacarbosereducedtheriskofdevelopingdiabetesby25 over3years Othermedicationstudiesareongoing InadditiontopreventingprogressionfromIGTtodiabetes bothlifestylechangesandmedicationhavealsobeenshowntoincreasetheprobabilityofrevertingfromIGTtonormalglucosetolerance Preventionordelayofdiabetes Medications ManagementofDiabetesMellitus Themajorcomponentsofthetreatmentofdiabetesare ManagementofDM Dietisabasicpartofmanagementineverycase Treatmentcannotbeeffectiveunlessadequateattentionisgiventoensuringappropriatenutrition Dietarytreatmentshouldaimat ensuringweightcontrolprovidingnutritionalrequirementsallowinggoodglycaemiccontrolwithbloodglucoselevelsasclosetonormalaspossiblecorrectinganyassociatedbloodlipidabnormalities A Diet Thefollowingprinciplesarerecommendedasdietaryguidelinesforpeoplewithdiabetes Dietaryfatshouldprovide25 35 oftotalintakeofcaloriesbutsaturatedfatintakeshouldnotexceed10 oftotalenergy Cholesterolconsumptionshouldberestrictedandlimitedto300mgorlessdaily Proteinintakecanrangebetween10 15 totalenergy 0 8 1g kgofdesirablebodyweight Requirementsincreaseforchildrenandduringpregnancy Proteinshouldbederivedfrombothanimalandvegetablesources Carbohydratesprovide50 60 oftotalcaloriccontentofthediet Carbohydratesshouldbecomplexandhighinfibre Excessivesaltintakeistobeavoided Itshouldbeparticularlyrestrictedinpeoplewithhypertensionandthosewithnephropathy A Diet cont Physicalactivitypromotesweightreductionandimprovesinsulinsensitivity thusloweringbloodglucoselevels Togetherwithdietarytreatment aprogrammeofregularphysicalactivityandexerciseshouldbeconsideredforeachperson Suchaprogrammemustbetailoredtotheindividual shealthstatusandfitness Peopleshould however beeducatedaboutthepotentialriskofhypoglycaemiaandhowtoavoidit Exercise Therearecurrentlyfourclassesoforalanti diabeticagents i Biguanidesii InsulinSecretagogues Sulphonylureasiii InsulinSecretagogues Non sulphonylureasiv glucosidaseinhibitorsv Thiazolidinediones TZDs B OralAnti DiabeticAgents Ifglycaemiccontrolisnotachieved HbA1c 6 5 and or FPG 7 0mmol Lor RPG 11 0mmol L withlifestylemodificationwithin1 3months ORALANTI DIABETICAGENTshouldbeinitiated Inthepresenceofmarkedhyperglycaemiainnewlydiagnosedsymptomatictype2diabetes HbA1c 8 FPG 11 1mmol L orRPG 14mmol L oralanti diabeticagentscanbeconsideredattheoutsettogetherwithlifestylemodification B 1OralAgentMonotherapy Asfirstlinetherapy Obesetype2patients consideruseofmetformin acarboseorTZD Non obesetype2patients considertheuseofmetforminorinsulinsecretagoguesMetforministhedrugofchoiceinoverweight obesepatients TZDsandacarboseareacceptablealternativesinthosewhoareintoleranttometformin Ifmonotherapyfails acombinationofTZDs acarboseandmetforminisrecommended Iftargetsarestillnotachieved insulinsecretagoguesmaybeadded B 1OralAgentMonotherapy cont Combinationoralagentsisindicatedin NewlydiagnosedsymptomaticpatientswithHbA1c 10Patientswhoarenotreachingtargetsafter3monthsonmonotherapy B 2CombinationOralAgents Iftargetshavenotbeenreachedafteroptimaldoseofcombinationtherapyfor3months consideraddingintermediate acting long actinginsulin BIDS Combinationofinsulin oralanti diabeticagents BIDS hasbeenshowntoimproveglycaemiccontrolinthosenotachievingtargetdespitemaximalcombinationoralanti diabeticagents Combininginsulinandthefollowingoralanti diabeticagentshasbeenshowntobeeffectiveinpeoplewithtype2diabetes Biguanide metformin Insulinsecretagogues sulphonylureas Insulinsensitizers TZDs thecombinationofaTZDplusinsulinisnotanapprovedindication glucosidaseinhibitor acarbose InsulindosecanbeincreaseduntiltargetFPGisachieved B 3CombinationOralAgentsandInsulin DiabetesManagementAlgorithm OralHypoglycaemicMedications Inelderlynon obesepatients shortactinginsulinsecretagoguescanbestartedbutlongactingSulphonylureasaretobeavoided Renalfunctionshouldbemonitored Oralanti diabeticagentsarenotrecommendedfordiabetesinpregnancyOralanti diabeticagentsareusuallynotthefirstlinetherapyindiabetesdiagnosedduringstress suchasinfections InsulintherapyisrecommendedforboththeaboveTargetsforcontrolareapplicableforallagegroups However inpatientswithco morbidities targetsareindividualizedWhenindicated startwithaminimaldoseoforalanti diabeticagent whilereemphasizingdietandphysicalactivity Anappropriatedurationoftime 2 16weeksdependingonagentsused betweenincrementsshouldbegiventoallowachievementofsteadystatebloodglucosecontrol GeneralGuidelinesforUseofOralAnti DiabeticAgentinDiabetes Short termuse Acuteillness surgery stressandemergenciesPregnancyBreast feedingInsulinmaybeusedasinitialtherapyintype2diabetesinmarkedhyperglycaemiaSeveremetabolicdecompensation diabeticketoacidosis hyperosmolarnonketoticcoma lacticacidosis severehypertriglyceridaemia Long termuse IftargetshavenotbeenreachedafteroptimaldoseofcombinationtherapyorBIDS considerchangetomulti doseinsulintherapy Wheninitiatingthis insulinsecretagoguesshouldbestoppedandinsulinsensitiserse g MetforminorTZDs canbecontinued C InsulinTherapy Themajorityofpatientswillrequiremorethanonedailyinjectionifgoodglycaemiccontrolistobeachieved How